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APPENDICITIS 


THE  ETIOLOGY,   HYGIENIC   AND 
DIETETIC  TREATMENT 


BY 

JOHN  H.  TILDEN,  M.D. 

^Author  of 

Impaired  Health,"  2  Vol.;  "Cholera  Infantum,"  "Typhoid 

Fever,"  "Diseases  of  Women  and  Easy  Childbirth," 

"Venereal  Diseases,"  "Appendicitis,"  "Care  of 

Children,"  "Food,"  2  Vol.;  "Pocket  Dietitian." 


DENVER,  COLORADO 

¥ 

ALL  RIGHTS  RESERVED 


5A"X 

,TSO> 


COPYRIGHTED,  1909 
COPYRIGHTED.  1915 
COPYRIGHTED,  1921 


PRINTED  AND  BOUND  BY 

THE  HARTMANN-BRUDERLIN  STATIONERY  CO. 

DENVER,  COLORADO 


THE  ROAD  OF  ILL  HEALTH 


To  understand  the  cause  of  appendicitis  we 
must  go  back  to  the  beginning,  and  when  we  do 
we  find  that  it  starts  just  where  all  diseases  start, 
namely,  where  health  leaves  off!  When  the  laws 
of  health  are  broken  for  the  first  time,  it  can  be 
said  that  the  individual  has  started  on  the  road  of 
ill  health.  How  fast  he  will  travel  and  just  what 
will  be  the  character  of  the  disease  he  meets  with 
will  depend  upon  his  constitution,  inheritance, 
environment  and  education. 


APPENDICITIS 


CHAPTER  I. 


This  cut  represents  the  back  view  of  the 
cecum,  the  appendix,  a  part  of  the  ascending  colon, 
and  the  lower  part  of  the  ileum,  with  the  arterial 
supply  to  these  parts. 


2  APPENDICITIS. 

"A,  ileo-eolic  artery;  B  and  F,  posterior  cecal 
artery;  C,  appendicular  artery;  E,  appendicular 
artery  for  free  end;  H,  artery  for  basal  end  of 
appendix;  1,  ascending  or  right  colon;  2,  external 
sacculus  of  the  cecum;  3,  appendix;  6,  ileum;  D, 
arteries  on  the  dorsal  surface  of  the  ileum.,, — 
Byron  Eobinson. 

The  reader  will  see  how  very  much  like  a  blind 
pouch  the  cecum  is,  2.  The  ileum,  6,  opens  into 
the  cecum,  all  of  the  bowel  below  the  opening  be- 
ing cecum,  the  opening  of  the  appendix,  3,  is  in 
the  lower  part  of  the  cecum. 

The  arterial  supply  to  these  parts  is  great 
enough  to  get  them  into  trouble  in  those  people 
who  are  imprudent  eaters,  and  it  is  also  great 
enough  to  save  the  parts  when  diseased  if  the 
patient  has  the  proper  treatment. 

For  the  benefit  of  the  lay  reader  I  will  say 
that  the  blood-vessels  represented  in  the  cut  are 
the  arteries;  there  are  also  veins,  nerves,  and 
lymphatics  imbedded  in  the  folds  of  the  peri- 
toneum, accompanying  and  paralleling  the  arter- 
ies, but  they  are  not  shown  in  the  cut. 

The  peritoneum  is  the  lining  membrane  of  the 
peritoneal  cavity.  It  is  well  to  remember  that 
there  is  nothing  in  the  peritoneal  cavity  except  a 
little  serum.  The  layman  will  say  that  the  bowels 
are  in  this  cavity,  but  they  are  not;  they  project 
into  the  cavity,  and  their  outside  covering  is  the 
lining  membrane  of  the    peritoneal    cavity,    but 


ANATOMY.  3 

they  are  truly  on  the  outside  of  the  cavity,  and  to 
enable  the  layman  to  understand  the  anatomy  so 
that  he  can  apply  it  when  reading  of  the  disease, 
I  shall  describe  the  course  of  an  ulcer :  If  an  ulcer 
starts  in  the  bowel  it  first  eats  through  the  mucous 
coat  which  is  the  lining  membrane  of  the  bowel, 
then  through  the  submucous  coat,  which  is  the 
second  layer  or  coat  of  the  bowel,  then  through 
the  muscular  coat,  which  is  the  third  layer  of  the 
bowel;  this  brings  the  ulcer  to  the  serous  coat  or 
peritoneum.  When  the  peritoneum  is  eaten 
through  it  is  called  perforation,  for  it  means  that 
there  is  an  opening  into  the  peritoneal  cavity,  and, 
unless  the  cavity  is  cut  into,  cleaned  and  properly 
drained,  death  will  take  place  in  a  very  short 
time.  I  say  death  is  inevitable  without  surgical 
treatment.  In  this  I  appear  to  be  more  radical 
than  the  most  radical,  for  the  best  authors  have 
much  to  say  about  perforation,  diffuse  peritonitis, 
and  of  patients  who  live  after  perforation,  as 
though  it  were  a  common  occurrence;  I  say  they 
are  mistaken. 


APPENDICITIS. 


CHAPTER  II. 


History:  Appendicitis  did  not  become  popu- 
larly known  until  about  twenty  years  ago — not  till 
it  was  christened  and  baptized  in  the  blood  of  the 
surgical  art.  Of  course  the  appendix  has  always 
been  subject  to  inflammation,  just  as  it  is  now, 
but  in  former  years  the  disease  we  call  appen- 
dicitis bore  various  names,  depending  upon  the 
diagnostic  skill  of  the  attending  physician. 
Typhlitis  and  perityphlitis  were  the  names  used 
to  designate  the  disease  now  covered  by  the  word 
appendicitis. 

The  diseases  that  appendicitis  may  be  con- 
founded with  and  must  be  differentiated  from  are 
obstruction,  renal  colic,  hepatic  colic,  gastritis, 
enteritis,  salpingitis,  peritonitis  due  to  gastric  or 
intestinal  ulcer,  enterolith,  obstipation,  invagina- 
tion or  intussusception,  hernia,  external  or  in- 
ternal, volvulus,  stricture  and  typhoid  fever. 

The  old  text-book  description  of  typhlitis  and 
perityphlitis  is  so  similar  to  the  description  of  the 
present  day  appendicitis  that  it  is  not  necessary 
to  reproduce  it.  The  symptoms  given  show  con- 
clusively that  they  are  really  one  and  the  same. 

In  the  surgical  treatment  of  appendicitis  the 
American  profession  has  taken  the  lead,  and  the 
mention  of  this  disease  brings  to  mind  such  names 


HISTORY.  5 

as  McBurney,  whose  name  is  given  to  an 
anatomical  point — McBurney 's  Point — midway 
between  the  right  anterior  superior  spine  of  the 
ilium  and  the  umbilicus,  Deaver  of  Philadelphia, 
and  Ochsner  and  Murphy  of  Chicago.  Those  who 
are  interested  in  the  surgical  treatment  of  the  dis- 
ease can  look  into  the  methods  of  these  men,  and 
many  others.  The  medical  literature  of  the  day 
abounds  in  exhaustive  treatises  on  the  subject  of 
appendicitis  and  its  surgical  treatment. 

We  are  living  in  an  age  that  will  not  be  prop- 
erly recorded  unless  it  be  entered  as  The  Age  of 
Fads. 

Following  immediately  on  the  announcement 
of  Lord  Lister's  antiseptic  surgical  dressing 
which  rendered  the  invasion  of  the  peritoneal 
cavity  comparatively  safe,  came  the  laparotomy 
or  celiotomy  mania.  When  it  was  discovered  that 
opening  the  abdomen  was  really  a  minor  opera- 
tion, it  was  soon  legitimatized  by  professional 
opinion,  and  rapidly  became  standardized  as  a 
necessary  procedure  in  all  questionable  cases — in 
all  obscure  cases  of  abdominal  disease — where  the 
diagnosis  was  in  doubt.  The  result  of  populariz- 
ing and  legitimatizing  the  exploratory  incision, 
was  to  cause  those  who  failed  to  resort  to  it,  in 
doubtful  cases,  to  be  in  contempt  of  the  court  of 
higher  medical  opinion,  and  to  license  those  of  a 
reckless,  selfish,  savage  nature  to  play  with  hu- 


6  APPENDICITIS. 

man  life  in  a  manner  and  with  a  freedom  that 
would  make  a  barbarian  envious. 

The  wave  of  abdominal  operations  that  swept 
the  country  in  the  last  quarter  of  the  nineteenth 
century  was  appalling.  The  slightest  pain  during 
menstruation,  or  in  the  lower  abdomen,  in  fact 
every  pain  that  a  woman  had  from  head  to  toes 
was  put  under  arrest  and  forced  to  bear  false 
witness  against  the  ovaries.  It  was  a  very  easy 
matter  to  trump  up  testimony,  when  real  evidence 
was  embarrassing,  to  foregone  conclusions ;  hence 
pains  in  obscure  and  foreign  parts  took  on  great 
importance  when  analyzed  by  minds  drilled  in  the 
science  of  nervous  reflexes,  sympathies  and  me- 
tastases. 

Normal  ovariotomy  (removing  normal 
ovaries  for  a  supposed  reflex  disease)  swept  the 
whole  country  during  the  eighties  and  threatened 
the  unsexing  of  the  entire  female  population.  The 
ovaries  had  the  reputation  of  causing  all  the 
trouble  that  the  flesh  of  woman  was  heir  to. 
Oophorectomy  was  the  entering  wedge,  since  then 
everything  contained  in  the  abdomen  has  become 
liable  to  extirpation  on  the  slightest  suspicion. 

Those  surgeons  of  greater  dexterity  or  sav- 
agery, I  can't  tell  which,  prided  themselves  in  op- 
erating on  the  more  difficult  cases.  Taking  the 
ovaries  out  was  a  very  tame  affair  compared  to 
removing  the  uterus,  tubes  and  ovaries ;  hence  the 
surgical  adept  embraced  every  opportunity  for  an 


SURGERY.  7 

excuse  to  remove  everything  that  is  femininely 
distinctive. 

About  1890  appendicitis  began  to  attract  the 
attention  of  those  surgically  ambitious.  The 
ovariotomy  or  celiotomy  expert  began  to  feel  the 
sting  of  envy  and  jealousy  aroused  by  those  who 
were  making  history  in  the  new  surgical  fad — 
appendicectomy — and  they  got  busy,  and,  as  dis- 
ease is  not  exempt  from  the  economic  law  of 
"supply  always  equals  demand,"  the  disease  ac- 
commodatingly sprang  up  everywhere;  it  was  no 
time  before  a  surgeon  who  had  not  a  hundred  ap- 
pendicectomies  to  his  credit  was  not  respected  by 
the  rank  and  file,  and  an  aspirant  for  entrance  to 
the  circle  of  the  upper  four  hundred  could  not  be 
initiated  with  a  record  of  fewer  than  one  thou- 
sand operations. 

Thanks  to  the  law  of  supply  and  demand  the 
ovaries  retired  and  gave  women  a  much  needed 
rest.  If  they  had  continued  to  misbehave  as  they 
had  been  doing  before  the  appendix  got  on  the 
rampage,  the  demand  for  surgical  work  would 
have  exceeded  the  supply  of  surgeons.  Diseases 
of  all  kinds  are  very  accommodating;  as  soon  as 
a  successful  rival  is  well  introduced  they  retire 
without  the  least  show  of  jealousy,  showing  that 
they  are  not  strangers  to  the  highest  ethics,  their 
associations  to  the  contrary  notwithstanding. 

There  are  many  well  written  articles  on  ap- 
pendicitis, but  I  believe  the  monograph  by  A.  J. 


8  APPENDICITIS. 

Ochsner,  M.  D.,  is  decidedly  the  best,  and  when  I 
refer  to  the  best  professional  ideas  on  etiology, 
pathology,  symptomatology  and  treatment  I  have 
in  mind  the  opinions  set  down  by  Ochsner,  for  he 
has  taken  more  advanced  grounds  in  the  medical 
treatment  of  this  disease  than  any  other  physi- 
cian I  know  anything  about  in  this  or  any  other 
country.  If  his  "A  Handbook  on  Appendicitis' ' 
brought  out  in  1902,  had  come  out  three  years  be- 
fore, I  should  give  him  credit  for  being  the  first 
man  on  record  to  proscribe  the  taking  of  food  in 
appendicitis,  but  as  my  first  written  advice  on  the 
subject  was  in  the  July,  1900,  number  of  A  Stuffed 
Club,  two  years  before  his  book,  I  shall  give  my- 
self the  credit  for  being  the  first  physician  to  an- 
nounce to  the  world  the  only  correct  plan  of  treat- 
ing the  disease  and  suggesting  the  probable  cause, 
which  the  intervening  time  has  proven  to  be  cor- 
rect. The  only  reason  I  have  for  making  this  an- 
nouncement is  that  in  all  probability  no  one  else 
will  ever  do  so,  and,  as  it  is  just  and  right  that  I 
should  have  the  credit,  I  do  myself  the  honor.  The 
general  rule  is  that  if  a  new  method  of  treatment 
comes  out,  or  a  discovery  of  importance  is  made 
other  than  in  the  regular  professional  channels,  it 
will  either  be  ignored  or  adopted  (cribbed  is  more 
expressive)  and  no  credit  given.  This  is  a  small 
matter,  and  of  no  special  consequence,  yet  it  car- 
ries a  meaning. 

Previous  to  1890  the  most  popular  treatment 


OPIUM  TREATMENT.  9 

was  probably  the  giving  of  opium;  although  this 
was  far  from  ideal,  "it  had  the  advantage  of  tak- 
ing away  the  patient's  appetite,  relieving  pain, 
and  putting  the  bowels  to  rest. ' '— Ochsner.  If 
there  were  any  way  to  prove  it,  we  should  find 
that  next  to  surgery  opium  is  still  the  most  popu- 
lar way  of  treating  the  disease. 

To-day  there  is  no  other  disease  which  brings 
surgery  so  quickly  to  mind  as  does  appendicitis, 
especially  if  the  victim  can  stand  for  a  good,  large 
fee.  It  is  only  human,  I  presume,  for  surgeons  to 
defend  the  operation.  They  believe  in  it,  and  are 
not  willing  to  investigate,  for  they  are  satisfied. 
They  know,  or  should  know,  that  ninety  per  cent, 
of  all  the  surgery  practiced  to-day  has  no  excuse 
for  its  existence — no  more  right  to  be  protected 
by  the  laws  that  weld  society  together  than  has 
any  other  graft  that  exists  by  the  grace  of  public 
ignorance  and  credulity.  This  operation  has  for 
some  time  been  the  largest  single  item  of  revenue 
for  the  profession. 

Thirty-four  years  ago  I  was  called  in  con- 
sultation to  see  my  first  case  of  what  was  then 
generally  recognized  as  perityphlitis  or  typhlitis 
— inflammation  of  the  connective  tissue  about  the 
cecum.  It  was  a  typical  case  of  what  is  today 
called  appendicitis.  I  advised  the  doctor  to  cease 
his  fruitless  endeavors  at  securing  relief  by  giving 
drugs,  and  give  the  patient  nothing  but  water. 
As  I  remember  now,  it  took  about  four  weeks  for 


10  APPENDICITIS. 

this  patient  to  recover.  This  plan — positively 
nothing  but  water — has  since  been  a  part  of  my 
treatment  in  all  such  diseases. 


ETIOLOGY.  11 


CHAPTER  III. 


Etiology:  To  understand  the  cause  of  ap- 
pendicitis we  must  go  back  to  the  beginning,  and 
when  we  do  we  find  that  it  starts  just  where  all 
diseases  start,  namely,  where  health  leaves  off! 
When  the  laws  of  health  are  broken  for  the  first 
time,  it  can  be  said  that  the  individual  has  started 
on  the  road  of  ill  health.  How  fast  he  will  travel 
and  just  what  will  be  the  character  of  the  disease 
he  meets  with  will  depend  upon  his  constitution, 
inheritance,  environment  and  education.  I  do  not 
mean  by  education,  school  or  book  education;  I 
mean  intuition — that  knowledge  which  evolves 
from  home  life  and  habits.  I  mean,  has  he  any 
self  -discipline  ?  Does  he  know  anything  about 
self-denial?  Has  he  any  conception  of  a  control 
higher  than  impulse  1  Has  he  been  brought  up  to 
know  that  there  is  a  limit  to  the  gratifying  of 
wants  and  desires  beyond  which,  if  he  goes,  he 
must  make  good  with  laws  that  are  as  exacting 
as  they  are  invariable?  Does  he  know  that  nature 
shows  no  favoritism?  Does  he  know  that  there 
are  laws  regulating  his  intercourse  with  men — 
with  everything — that  exact  absolute  justice  from 
him?  And  that,  if  he  takes  advantage  of  weak- 
ness or  ignorance  because  he  can,  or  if  he  secures 
an  advantage  through  credulity  or  trickery,  he 


12  APPENDICITIS. 

must  settle  for  the  crime  before  a  judge  who  is 
absolutely  just?  If  he  has  this  education,  which 
is  a  constitutional  ingrafting  from  the  mother's 
blood,  fructified  by  a  like  potential  father,  he  will 
be  almost  immune  from  all  diseases.  This  is  an 
education  that  can  not  be  secured  unless  the  in- 
dividual has  the  prenatal  and  environing  influ- 
ences to  differentiate  these  static  attributes  of  his 
nature,  and,  if  he  has,  the  result  will  be  that  all 
these  qualities  will  come  to  him  because  "like  at- 
tracts like.,,  In  an  atmosphere  where  others  at- 
tract evil  this  individual  attracts  good.  The  same 
is  true  on  the  physical  plane.  Those  who  have 
diseased  bodies  always  have  disease  making  hab- 
its, hence  they  attract  from  a  given  environment 
all  the  disease  making  impulses,  while  those  of 
healthy  bodies  have  health  imparting  habits,  and 
attract  from  the  same  environment  the  health  im- 
pulses for  which  they  have  an  affinity. 

The  constitution,  inheritance  and  education  of 
all  mankind  will  vary  from  the  highest  to  the  low- 
est types.  As  we  go  down  the  scale  from  those 
with  ideal  physical  and  mental  health,  we  see  man 
becoming  more  and  more  the  victim  of  disease. 

It  is  no  uncommon  thing  to  find  people  of 
seeming  intelligence  who  appear  surprised  when 
told  that  they  have  brought  upon  themselves  such 
a  vulnerable  state  of  health  from  wrong  eating 
and  care  of  their  bodies  that  they  are  in  line  for 
appendicitis,  pneumonia,  typhoid  fever,  bowel  ob- 


CROWDED  NUTRITION.  13 

struction,  or  blood  poisoning.  In  such  types  blood 
poisoning  would  surely  follow  a  complicated  frac- 
ture of  a  bone— a  fracture  where  the  ends  of  the 
bone  cut  through  the  flesh  causing  an  open  wound. 

Pregnant  women  belonging  to  this  class  go 
into  confinement  with  their  blood  so  heavily 
charged  with  the  by-products  of  an  imperfect 
metabolism  that  they  are  very  liable  to  have 
septicemia. 

People  who  think  they  must  have    "  three 
square  meals  a  day"  must  have  catarrh,  rheu- 
matism, tonsilitis,  quinsy,    pneumonia,    typhoid 
fever,  and  all  sorts  of  bowel  trouble  including  ap- 
pendicitis.   Why?  Because  three  meals  a  day  con- 
sisting of  bread,  potatoes,  eggs,  meat,  fish,  butter, 
milk,  cheese,  beans,  etc.,  overwork  the  metabolic 
function  and  as  a  consequence  organic  function- 
ing is  impaired,  cell  proliferation  falls  below  the 
ideal,  bodily  resistance  falls  lower  and  lower,  the 
intestinal  secretions  lose  their  immunizing  power 
more  and  more,  until  at  last  the  body  becomes 
the  victim  of  every  adverse  influence.      At  first 
fermentation— indigestion  —  shows  occasionally; 
the  intervals      between    these    attacks    of    acid 
stomach,    or    fermentation,    grow    shorter    and 
shorter  until  they  are  of  daily  occurrence;  accom- 
panying this  fermentation  there  is  gas  distention 
of  the  bowels,  and  this  inflation  in  time  interferes 
with  their  motility  and  weakens  them  so  that  slug- 
gishness is  succeeded  by  obstinate  constipation. 


14  APPENDICITIS. 

Every  step  of  this  evolution  shows  an  in- 
creasing toxic  state  of  the  fluids  in  the  bowels. 
After  constipation  is  established  the  efforts  at  se- 
curing evacuations  are  of  such  a  nature  as  to  irri- 
tate the  cecum.  Drugs  to  force  movement  cause 
painful  distentions  of  this  portion  of  the  bowels. 
The  drugs  stimulate  peristalsis  of  the  small  intes- 
tine ;  each  wave  from  the  small  intestine  breaks  on 
the  walls  of  the  cecum,  for  the  colon  is  loaded  with 
fecal  accumulations  so  that  the  onrushing  con- 
tents of  the  small  intestine  can  not  be  received  by 
the  colon;  hence  the  force  of  the  whole  peristaltic 
impact  is  spent  on  the  cecum,  which  must  en- 
danger the  integrity  of  the  mucosa  as  well  as  the 
musculature. 

This  point  of  the  bowels,  the  cecum,  is  more 
endangered  from  diarrhea  than  any  other.  The 
toxic  ptomaines  are  especially  liable  to  create  a 
local  infection  if  nothing  more. 

This  state  of  the  intestines — toxic  state — is 
a  constant  menace  to  health ;  in  fact  the  organism 
is  heavily  taxed  to  maintain  its  defense. 

The  overcrowding  of  metabolism,  as  explained 
above,  the  chronic  constipation  and  toxic  bowel 
secretions,  I  recognize  as  the  chief  factors — the 
necessary  and  leading  factors — in  the  building 
and  maintaining  of  that  constitutional  state  which 
I  am  pleased  to  denominate  Constitutional  Ca- 
tarrh. When  this  state  is  established,  it  can  be 
said  that  the  individual  is  ready  to  develop  any 


CONSTITUTIONAL  CATARRH.  15 

phase  of  disease  that  circumstance,  accident,  or 
caprice  of  fortune  or  environment  may  offer. 

The  constant  presence  of  gas  in  the  bowels  be- 
comes more  and  more  menacing  to  the  cecum  as 
the  constipation  increases.  The  filled-up  condi- 
tion of  the  bowels — the  colon  and  rectum — pre- 
vents the  easy  passage  of  gas  from  the  bowels, 
hence  it  accumulates  in  the  ileo-cecal  region  and 
keeps  the  cecum  distended. 

The  constant  dilating  of  the  cecum  from  gas 
accumulations  and  the  forced  dilations  from 
diarrheas  made  either  from  drugs  or  irritating 
foods,  must  not  only  damage  the  cecum  but  the 
appendix  as  well;  for  the  appendix  opens  into 
this  part  of  the  intestine  and  it  is  reasonable  to 
believe  that  it  suffers  distention  from  gas  and  that 
toxic  secretions  are  driven  into  it.  When  its  func- 
tion is  not  interfered  with  by  an  unusual  pressure 
as  from  constipation,  no  doubt  it  can  empty  itself 
and  does  do  so. 

When  it  is  understood  first  of  all  that  appen- 
dicitis— the  inflammation  known  as  appendicitis — 
is  a  local  manifestation  of  a  general  or  constitu- 
tional derangement,  the  cause  for  this  local  mani- 
festation may  be  taken  up. 

In  order  to  understand  why  the  disease  local- 
izes we  must  refer  the  reader  to  the  peculiar  an- 
atomical construction  of  the  cecum  and  the  ap- 
pendix, and  their  relation  to   other  parts.      The 


16  APPENDICITIS. 

cecum  is  a  large,  blind  pouch,  one  of  the  shortest 
of  the  several  divisions  in  the  continuity  of  the 
intestinal  canal,  which  begins  where  the  small  in- 
testine ends,  and  ends  where  the  large  intestine 
begins.  Its  blind  end  or  pouch  is  down;  this  de- 
pendent position  makes  it  peculiarly  liable  to  im- 
paction and  the  injuries  which  are  disposed  to 
come  from  distention;  for,  as  the  colon  ascends 
from  its  connection  with  the  cecum,  the  force  of 
gravity  must  be  reckoned  with. 

The  colon  is  very  liable  to  be  more  or  less  dis- 
tended with  accumulations,  and  especially  is  this 
true  of  those  of  sedentary  habits,  for  a  call  to 
evacuate  the  bowels  is  frequently  postponed. 

This  postponing  of  duty  to  nature  has 
evolved,  in  all  these  years  of  civilized  life,  a  weak- 
ened functioning  so  that  man  is  more  subject  to 
constipation  than  any  other  animal.  The  bowels 
are  educated  to  tolerate  a  great  accumulation  and 
the  pretty  general  habit  of  taking  drugs  to  force 
action  has  grown  a  weakened  state  which  is  the 
natural  sequence  of  overstimulation  and  as  this 
has  been  going  on  generation  after  generation  it 
has  become  more  or  less  transmissible. 

The  cecum,  situated  as  it  is,  must  bear  the 
brunt  of  the  evil  effects  of  constipation.  When 
the  large  intestine  is  full  or  distended,  as  it  usu- 
ally is  in  cases  of  chronic  constipation,  so  that 
nothing  can  pass  out  of  the  cecum  this  organ  be- 
comes a  jetty  head,  so  to  speak,  against  which  the 


CONSTIPATION.  17 

peristaltic  waves  from  the  small  intestine  break. 
The  full  force  of  the  peristaltic  waves  from  the 
small  intestine  with  its  onrush  of  fluid  or  semi- 
fluid contents  subjects  the  cecum  to  great  disten- 
tion and  strain. 

If  there  were  any  way  to  prove  that  so-called 
appendicitis  is  more  common  to-day  than  in  former 
times,  it  is  reasonable  to  believe  that  the  irritating 
effect  of  the  pretty  general  habit  of  taking  cathar- 
tic medicine  has  had  more  to  do  with  bringing  it 
about  than  any  other  one  thing. 

Distention,  with  the  straining  of  the  walls 
from  peristaltic  onrushes  as  described  above,  and 
the  infection  that  this  part  of  the  alimentary  canal 
is  subjected  to  because  of  the  decomposition  of 
food  that  is  going  on  to  a  greater  or  less  extent 
in  all  victims  of  constipation,  are  the  causes  of 
inflammation  in  the  cecum.  If  the  inflammation 
involves  the  appendix  or  the  cecal  location  of  the 
appendix,  it  may  be  called  appendicitis,  but  the 
appendix  is  involved  the  same  as  any  other  con- 
tiguous part.  Any  mind  capable  of  reasoning 
should  have  no  trouble  in  rightly  assigning  the  re- 
sponsibility of  this  disease,  if  sufficient  attention 
be  given  to  anatomism. 

There  is  not  any  very  good  reason  for  one 
capable  of  analyzing,  to  jump  at  the  conclusion 
that  the  appendix  is  the  cause  of  the  disease  be- 
cause it  is  frequently  found  in  the  field  of  inflam- 


18  APPENDICITIS. 

mation.  The  same  reasoning  would  make  Peyer's 
glands  the  cause  of  typhoid  fever. 

The  unwholesome  condition  of  the  intestinal 
tract  which  is  the  immediate  or  exciting  cause  of 
appendicitis  and  other  diseases  peculiar  to  this 
location,  is  brought  on  by  improper  life;  not  one 
cause,  nor  a  dozen  special  causes,  but  anything 
and  everything  that  break  down  the  general 
health  create  this  condition;  then  add  the  acci- 
dental eating  of  decomposition,  or  add  decomposi- 
tion, auto-generated,  and  we  have  the  necessary 
data. 

The  opening  of  the  appendix  is  so  very  small 
that  inflammation  of  the  cecum  soon  closes  it  and 
then  we  have  a  mucous  surface  without  drainage, 
which  means  obstruction — opposition  to  the  re- 
quirements of  nature — for  one  of  the  functions 
of  the  mucous  membrane  is  to  secrete  and  this 
secretion  must  have  an  outlet  or  the  part  becomes 
diseased. 

According  to  the  theory  of  bacteriology  a 
micro-organism  is  to  blame  for  appendicitis.  If 
this  were  true  it  would  relieve  humanitv  of  all  re- 
sponsibility.  There  is  a  disposition  on  the  part  of 
man  to  shirk  responsibility  and  the  germ  theory 
is  not  the  first  theory  of  vicarious  atonement  that 
he  has  spun.  Those  who  wish  to  shirk  all  kinds  of 
responsibility  by  adopting  the  germ  theory  and 
by  making  micro-organisms  the  scape-goat  may 
do  so,  but  I  would  advise  all  sensible  people  to 


MICRO-ORGANISMS.  19 

keep  in  mind  the  following  truth:  Violated  hy- 
gienic laws  predispose  to  disease;  then,  when  re- 
sistance is  broken  down,  the  immediate  and  ex- 
citing cause  may  be  anything  capable  of  laying  on 
the  "last  straw." 

The  micro-organisms  are  present  wherever 
there  is  life  and  are  as  necessary  to  life  as  they 
are  to  death. 

Ochsner  states  that  in  nearly  all  instances  the 
disease  can  be  traced  to  the  common  colon  bacillus, 
which  is  always  present  when  the  intestine  is  nor- 
mal. The  three  pus  cocci  are  sometimes  blamed, 
and  so  are  the  bacilli  of  typhoid  fever,  tubercu- 
losis and  the  ray  fungus  (so-called  cause  of  lump- 
jaw). 

Other  causes  given  are :  Edema  and  conges- 
tion closing  the  lumen  of  the  appendix,  thus  pre- 
venting drainage ;  constipation ;  digestive  disturb- 
ances ;  traumatism ;  eating  too  freely  while  in  an 
exhausted  condition. 

"  Whatever  the  predisposing  causes  may  be  in 
any  given  case,  the  exciting  cause  is  always  some 
infectious  material.  The  colon  bacillus  is  always 
present  in  the  lumen  of  the  alimentary  canal  and, 
although  it  is  harmless  under  normal  conditions, 
when  these  conditions  are  changed  and  there  is 
an  abrasion,  an  abnormal  condition  of  the  circula- 
tion, or  a  lack  of  drainage,  it  becomes  at  once  ac- 
tively pathogenic.  With  a  perfectly  normal  peri- 
toneum a  considerable  quantity  of  a  pure  culture 


20  APPENDICITIS. 

of  colon  bacilli  may  be  injected  into  the  abdominal 
cavity  without  causing  any  harmful  effect,  as  has 
been  shown  by  the  experiments  of  Ziegler,  but  if 
there  is  any  disturbance  in  the  circulation  or  nutri- 
tion of  the  peritoneum,  the  same  quantity  taken 
from  the  same  culture  will  give  rise  to  a  dangerous 
peritonitis. ' y — Ochsner.  [This  goes  back  to  the 
constitutional  derangement.  First  of  all  low  re- 
sistance, then  any  exciting  cause  is  sufficient.] 

In  studying  the  cause  of  organic  disease,  the 
first  thing  to  consider  is  the  organ  itself.  A 
knowledge  of  its  structure  and  function  will  in- 
dicate what  diseases  it  is  liable  to  have — what  the 
character  of  the  disease  must  be. 

Eeason  would  say  that  an  organ  can  be  de- 
ranged in  two  general  ways,  namely:  structural- 
ly and  functionally.  In  a  structural  way  it 
may  be  impaired  either  by  coming  in  violent 
contact  with  extraneous  objects,  or  it  may  be 
crowded  or  pressed  upon  by  enlarged  or  displaced 
associate  organs.  In  a  functional  way  the  de- 
rangement may  be  brought  about  from  overwork 
or  underwork.  A  digestive  organ  may  be  over- 
worked by  being  given  too  much  food,  or  food  of 
too  stimulating  a  quality ;  or  the  over-stimulation 
may  come  from  poisons  coming  into  the  food  from 
without  or  developing  in  the  food  after  its  inges- 
tion. The  bowels  may  be  injured  by  coming  in 
violent  contact  with  external  objects.    When  this 


INTESTINAL    DIGESTION.  21 

is  the  cause  there  will  be  the  history  of  accident, 
etc. 

The  functions  of  the  bowels  are  to  furnish  a 
dissolving  fluid  which  is  secreted  by  glands  sit- 
uated in  their  structure  and  opening  into  their 
lumen;  besides  the  secreting  glands  they  are  pro- 
vided with  power  to  excrete  and  absorb.  The  or- 
gans for  the  accomplishment  of  these  purposes, 
like  the  secretory  glands,  are  situated  in  the  struc- 
ture and  open  into  the  canal.  Besides  the  func- 
tions of  secretion,  excretion  and  absorption,  the 
bowels  act  as  the  great  sewer  of  the  body. 

The  dissolving  fluids,  or  digestive  fluids,  have 
the  power  to  overcome  fermentation  when  the  gen- 
eral health  standard  is  normal;  when  the  tone  of 
the  general  health  is  lowered  these  digestive  juices 
are  lacking  in  power;  hence  they  are  not  able  to 
control  fermentation  if  food  be  ingested  to  the 
amount  usually  taken  in  health.  The  power  to 
oppose  fermentation  by  the  digestive  juices 
ranges  all  the  way  from  nil  to  the  resistance  usual 
to  a  man  of  full  health  and  vigor. 

It  being  the  function  of  the  bowels  to  digest 
food  and  overcome  fermentation,  it  stands  to  rea- 
son that  to  accomplish  this  function  they  must  be 
normal — they  must  have  a  proper  supply  of  nerve 
force — and  the  supply  of  nutrition  must  be  nor- 
mal or  they  can  not  furnish  the  proper  amount 
and  quality  of  secretions.  To  have  all  these  needs 
supplied  they    must  be  reciprocally    related    to 


22  APPENDICITIS. 

every  other  organ  associated  with  them  in  the 
organic  colonization  which  totals  a  human  being. 

On  account  of  the  reciprocal  relationship  be- 
tween the  bowels  and  the  rest  of  the  colony  of 
organs,  the  bowels  must  share  alike ;  that  is,  in  the 
matter  of  distribution  of  forces  no  organ  of  the 
body  can  be  favored ;  all  must  go  up  and  all  must 
come  down  together.  They  must  all  share  alike; 
hence  the  bowels  have  their  share  of  the  general 
tone  and,  if  they  are  required  to  do  more  than  a 
reciprocal  amount  of  the  work,  it  stands  to  reason 
that  they  can  not  do  good  work;  and,  if  they  can 
not  do  good  work,  the  whole  colony  must  suffer 
in  a  general  way,  while  the  bowels  must  also  suffer 
in  a  special  way.  The  function  of  drainage  or 
sewerage  is  very  important,  and  the  perversion 
of  it  brings  on  much  ill  health.  The  principal  per- 
version to  the  function  of  sewerage  is  that  of  con- 
stipation, the  location  of  which  is  limited  to  the 
lower  portion  of  the  large  intestine,  a  section  of 
the  canal  least  endowed  with  digestive  and  ab- 
sorptive power. 

The  result  of  overwork  is  depression — ex- 
haustion— prostration;  and  what  does  that  mean 
to  an  organ?  Is  it  possible  for  an  overworked 
organ — a  depressed  organ — an  exhausted  organ — 
a  prostrated  organ — to  function  normally?  Is  it 
reasonable  to  believe  that  an  organ  that  is  in- 
flamed can  function  properly?  Such  questions  are 
absurd,  I  acknowledge.    Questions  that  carry  fore- 


SUSPENDED  NUTRITION.  23 

gone  conclusions  on  the  face  of  them  write  the 
questioner  down  an  ass,  which  I  also  acknowledge. 
But  I  desire  to  rebut  the  inference  these  questions 
reflect  on  me  by  making  a  few  requests  which 
show  that  there  is  a  lot  of  professional  reasoning 
based  on  that  sort  of  logic  which  justifies  my  child- 
ish, senseless  questions. 

Show  me  a  physician,  or  if  you  can  not  show 
me  one,  give  me  the  name  of  a  physician  who  does 
not  feed  children  in  cholera  infantum.  I  want  to 
know  a  few  physicians  who  do  not  feed  in  typhoid 
fever.  I  should  like  to  make  the  acquaintance  of 
a  few  physicians  who  do  not  feed  in  appendicitis 
until  the  disease  is  made  desperate,  and  who  do 
not  begin  to  feed  long  before  it  is  safe  to  feed. 

In  all  diseases  where  there  is  fever,  in  all  dis- 
eases where  there  is  pain,  nutrition  is  suspended 
— metabolism  is  stationary.  I  wish  some  one 
would  be  kind  enough  to  inform  me  of  an  M.  D. 
who  does  not  feed  patients  suffering  with  pain 
and  fever. 

If  the  inferences  these  requests  carry  are 
true,  has  the  personnel  of  the  profession  any  right 
to  treat  my  questions  with  contempt  and  declare 
that  they  are  childish? 

No !  Diseased  organs  can  not  function  prop- 
erly and  it  is  absurd,  yes  worse  than  that,  it  is 
criminal  to  feed  under  such  circumstances.  The 
result  of  feeding  is  the  prolongation  of  disease  by 
building  it  afresh  with  every  spoonful  of  food. 


24  APPENDICITIS. 

I  say  that  every  relapse  and  every  complica- 
tion that  have  ever  occurred  in  any  disease  being 
treated  by  any  physician  from  the  top  to  the  bot- 
tom of  the  profession,  even  if  the  treatment  was 
the  very  best  that  could  be  furnished  by  the  high- 
est skill  in  any  of  the  drug-systems,  if  said  treat- 
ment consisted  of  drugging  and  feeding,  were 
brought  on  by  the  treatment. 

All  diseases  of  the  alimentary  canal,  not  of  a 
traumatic  origin  or  from  the  accidental  or  inten- 
tional swallowing  of  corroding  chemicals  or  from 
the  continuous  use  of  drugs  on  the  advice  of  physi- 
cians, come  from  infection  or  intoxication.  Why 
not?  This  is  the  most  reasonable  cause,  for  the 
fecal  matter  in  health  is  toxic  and  it  only  requires 
one  step  further  to  sufficiently  intensify  the  putre- 
factive change  to  create  irritation  of  the  mucous 
membrane.  Of  course  there  is  a  degree  of  im- 
munization taking  place  all  the  time.  Many  peo- 
ple have  themselves  inured  to  the  constant  satura- 
tion of  fecal  intoxication.  It  is  true  they  are 
building  a  large  toleration  for  that  particular 
poison,  but  their  general  vital  tone  is  being  low- 
ered continually  and  somewhere  and  in  some  way 
there  is  a  deposition  taking  place.  In  women 
there  may  be  an  old  cicatrix  in  the  neck  of  the 
womb  or  a  lump  in  the  breast ;  the  circulation  has 
been  impaired  for  several  years  and  now  because 
of  the  overstimulation  that  has  been  going  on  so 
long,  there  is  a  greatly  enfeebled  circulation  and 
deposits  are  taking  place.     The  tumor    in    the 


CONSTIPATION.  25 

breast  becomes  cancerous;  the  scar  in  the  womb 
takes  on  malignancy ;  the  arteries  harden ;  the  cir- 
culation in  the  spinal  cord  becomes  so  impaired 
that  induration  is  induced  followed  by  ataxia ;  and 
other  troubles  of  a  like  character  could  be  men- 
tioned. These  are  the  most  favorable  results  for, 
while  these  cases  are  winding  their  weary,  slug- 
gish course  to  the  land  of  rest,  there  have  been 
many  taking  the  rapid  transit. 

I  v/ish  to  emphasize  the  fact  that  one  of  the 
constant  symptoms  peculiar  to  this  class  of  in- 
ebriates is  constipation.  As  a  class  these  people 
carry  very  large  quantities  of  fecal  matter  in  their 
lower  bowels.  This  constantly  loaded  condition 
of  the  lower  bowels  is  relieved  occasionally  by  a 
sharp,  irritative  diarrhea,  accompanied  by  nausea 
and  vomiting  or  not.  The  diarrhea  is  often  pre- 
ceded by  a  few  hours  of  acute  pain  that  causes 
some  talk  of  appendicitis  and  operation  but,  much 
to  the  discomfiture  of  the  doctor,  the  bowels  start 
up  and  relieve  all  suffering. 

A  few  of  these  cases  develop  a  chronic  colitis. 
The  bowel  discharges  are  more  or  less  coated  with 
catarrhal  secretion.  Not  all  are  constipated;  ob- 
stinate diarrhea  is  the  character  of  some;  there 
are  here  and  there  a  few  cases  that  throw  off  a 
membrane  two  or  three  times  a  year,  often  in  ap- 
pearance like  a  cast  of  the  lumen. 

Enteritis,  entero-colitis  and  dysentery  are 
different  forms  of  bowel  troubles  that  cause  much 


26  APPENDICITIS. 

uneasiness,  for  it  is  such  a  common  matter  to  call 
everything  appendicitis,  and  if  the  patient  is 
credulous  and  gullible  he  may  be  operated  upon 
even  if  his  disease  is  a  proctitis  or  a  case  of  gas 
in  the  bowels. 

It  is  no  uncommon  thing  for  a  case  of  ob- 
stinate constipation,  accompanied  by  colic,  to  be 
operated  upon  for  removal  of  the  appendix  if  the 
pain  is  obstinate  and  hangs  on  long  enough  for 
the  patient  to  be  scared  into  an  operation.  The 
pressure  from  constipation  and  the  constant  strain 
on  the  cecum  render  this  particular  section  of  the 
bowels  liable  to  take  on  local  inflammations. 

The  recognized  literature  of  the  day  attrib- 
utes all  infectious  disease  to  germs  or  micro-or- 
ganisms. That  all  diseases  originating  in  the  ali- 
mentary canal  are  due  to  infection  there  can  be  no 
doubt,  and  all  agree,  but  I  do  not  agree  with  the 
prevailing  opinion  that  germs  or  micro-organisms 
are  the  primary  cause  of  infection,  for  that  theory 
is  not  sufficient;  it  can  not  possibly  cover  the 
ground  and  account  for  everything  that  takes  a 
part  in  the  great  array  of  causations  that  must 
be  considered.  To  my  mind  it  would  be  just  as 
reasonable  to  say  that  germs  cause  health,  and 
I  defy  any  bacteriologist  to  prove  that  micro- 
organisms cause  disease  any  more  than  they  cause 
health ;  and  if  he  can  't  prove  that  germs  are  more 
pathologic  than  they  are  physiologic,  but  does 
succeed  in  proving  that  they  are  equally  important 


GERMS  IN  HEALTH.  27 

to  health  and  to  disease,  we  can  agree  to  that 
equal  importance  and  should  be  able  to  go  on 
agreeing  and  declare  that  if  germs  are  the  cause 
of  disease  they  must  also  cause  health  and  it  is 
our  duty  to  spend  at  least  a  part  of  our  profes- 
sional time  in  cultivating  health  germs.  In  fact  it 
would  be  much  better  to  spend  all  our  time  in 
cultivating  health  germs  and  insisting  on  people 
being  inoculated  with  the  serum  from  these  germs 
so  that  there  will  develop  such  a  state  of  health 
that  the  disease  germs  will  have  no  show. 

How  can  a  sane  man  forgive  himself  for  ad- 
vocating inoculation  by  disease  germs  to  cause  im- 
munization when  by  the  use  of  health  germs  the 
health  could  be  built  so  strong  that  the  pathogenic 
germs  would  have  no  show.  If  this  theory  won't 
work  both  ways  it  is  a  false  theory,  and  profes- 
sional men,  who  should  be  logical  if  any  set  of 
men  are  logical,  should  be  ashamed  to  advocate 
any  theory  that  is  based  upon  a  half-truth. 

As  I  stated,  the  structure  and  function  of  an 
organ  point  to  its  possible  maladies.  The  cecum 
is  the  gate-way  between  the  large  and  small  in- 
testines. Its  function  of  passing  the  contents  of 
the  small  intestine  into  the  large  is  obstructed 
much  of  the  time.  It  is  constantly  subjected  to 
bruising,  pressure,  stretching,  and  obstruction, 
and  is,  therefore,  more  liable  to  be  the  seat  of 
local  inflammations  than  any  other  part  of  the 
bowels.    Diseases  of  this  part  of  the  bowels  are 


28  APPENDICITIS. 

liable  to  come  at  any  time  of  the  year ;  but  in  hot 
weather  the  tendency  to  fermentation  is  much 
greater  than  at  other  times  of  the  year,  and  bodily 
resistance  is  reduced  because  of  the  enervating  in- 
fluence of  the  heat,  of  too  long  working  hours,  and 
of  too  short  nights  for  sleep,  and  of  the  ever-pres- 
ent, omnipotent  and  omniverous  appetite  which  is 
taking  into  the  stomach  and  bowels  food  beyond 
the  digestive  capacity  both  in  quantity  and  qual- 
ity; all  these  join  in  intensifying  the  habitual  tox- 
icity of  the  bowel  contents  to  such  a  state  of 
virulence  that  those  parts  of  the  bowels  already 
weakened,  because  of  the  mechanical  injuries  be- 
fore referred  to,  take  on  a  local  inflammation. 
Diarrhea  may  be  the  consequence  and  the  bowels 
may  have  a  thorough  cleaning  out  and  the  whole 
trouble  end  in  a  few  days.  Or  the  constipation 
may  be  of  a  nature  that  evacuations,  such  as  the 
patient  has  been  having,  have  been  passing 
through  the  center,  leaving  a  coating  on  the  lumen, 
but  hollowed  out  in  the  center.  When  the  inflam- 
mation starts  causing  increased  bowel  contractions 
— peristalsis — there  is  a  breaking  down  of  the 
walls  of  this  fecal  ring  resulting  in  complete  ob- 
struction. The  ineffectual  bowel  contractions 
then  serve  to  irritate  and  inflame  the  affected  part 
still  more.  The  local  inflammation  is  at  first 
superficial  but  the  increasing  toxicity  of  the  fluids 
that  are  held  on  these  parts  causes  the  inflamma- 
tion to  take  on  ulceration. 


LOCAL  CAUSES.  29 

The  inflammation  or  ulceration  may  remain 
superficial,  and  be  located  in  the  lower  portion  of 
the  small  intestine,  then  the  disease  is  enteritis. 
If  the  bowels  are  cleared  out  and  the  patient's 
blood  freed  from  intoxication,  the  attack  ends ;  if 
not  the  disease  will  be  called  enteritis  or  catarrh. 
If  the  infection  is  a  little  greater  and  extends  a 
little  deeper  causes  inflammation  of  Peyer's 
glands  then  the  type  of  the  disease  will  be  typhoid 
fever. 

Children  troubled  with  constipation  will  some- 
times be  taken  with  fever  and  pain  in  the  right 
iliac  fossa  and,  on  examination,  a  fulness  will  be 
found;  the  sensitiveness  will  not  be  so  great  but 
that  an  examination  can  be  made  and  a  sausage 
shaped  tumor  may  be  outlined ;  of  course,  the  dis- 
ease will  be  named  appendicitis  and  this  is  enough 
to  scare  a  whole  neighborhood,  and  the  child  will 
be  carted  off  to  a  hospital  and  operated  upon  for 
appendicitis. 

If  the  child  is  left  alone,  given  no  food,  and 
ice  put  on  the  sensitive  parts  if  the  temperature 
is  103°  F.,  or  hot  applications  if  the  temperature 
is  less,  the  tenderness  will  probably  go  away  in 
two  or  three  days ;  if  it  does  not,  an  abscess  will 
form  and  empty  into  the  cecum.  If  the  child  is 
fed,  and  the  tumor  manipulated — subjected  to  un- 
necessary examinations — the  abscess  may  be  made 
to  burrow  down  toward  the  groin,  which  should 
be  avoided  for  it  is  a  very  undesirable  complica- 


30  APPENDICITIS. 

tion.  The  first  abscess  is  typhlitic,  the  second  is 
perityphlic.  The  first  may  form  without  the  aid 
of  bruising  in  the  manipulation  of  repeated  ex- 
aminations, but  the  second  must  be  forced  by  bad 
management.  The  latter  abscess,  I  have  reason 
to  believe,  is  the  former  abscess  driven,  by  re- 
peated manipulations,  to  burrow  downwards  in- 
stead of  opening  into  the  cecum. 

Fecal  abscess,  arising  from  ulceration  of  the 
colon,  may  be  mistaken  for  appendicitis.  There 
is  a  localized  swelling,  immovable  in  breathing  or 
when  pressed  upon,  and  having  a  tympanitic 
sound  on  percussion  over  it  with  dull  sound  on 
pressure  and  heavy  stroke. 

The  symptoms  of  appendicitis  are:  Pain  in 
the  front,  lower,  right  side  of  the  abdomen.  It  is 
paroxysmal  and  caused  in  the  main  by  peristalsis 
— the  regular  action  characteristic  of  the  sewer 
function  of  the  bowels,  which  is  for  the  purpose 
of  forcing  the  contents  of  the  intestines  onward 
to  the  outlet,  and  which  ordinarily  is  carried  on 
without  pain;  but,  in  bowel  obstructions  of  any 
kind,  the  onward  flow  of  the  bowel  contents  is  cut 
off  resulting  in  great  pain  where  there  is  much 
irritability,  for  irritation  of  any  kind  always  in- 
creases this  expulsive  movement.  Food,  taken  in 
health,  stimulates  this  contraction  and  if  taken 
when  there  is  inflammation — enteritis,  colitis  or 
inflammation  of  any  part— the  contraction  is  in- 
creased and  necessarily  painful.     Think  of  the 


COLIC  AND  DIARRHEA.  31 

pain  that  the  subject  of  diarrhea  has,  then  im- 
agine what  that  pain  must  be  if  there  should  be 
obstruction  so  that  the  fecal  matter  could  not  pass. 
That  is  as  near  as  I  can  describe  what  the  pain  of 
appendicitis  is.  Anything  that  will  stimulate  these 
contractions  will  throw  the  patient  into  great  dis- 
tress. Food  or  drugs  will  cause  pain,  and  water, 
the  first  few  days  of  the  illness,  will  do  the  same. 

In  inflammation  of  the  cecum,  where  the  in- 
flammatory process  remains  local  and  there  is  no 
obstruction  more  than  constipation  will  make,  the 
patient  will  be  troubled  with  occasional  attacks  of 
pain  which  will  pass  as  colic;  or  there  may  be  a 
diarrhea,  lasting  for  a  day,  every  few  weeks  or 
months  with  constipation  between  the  attacks. 
These  cases  may  lead  in  time  to  ulceration,  then 
to  fecal  abscesses  and  they  are  often  diagnosed 
chronic  appendicitis. 

When  the  inflammation  is  confined  to  that 
portion  of  the  cecum  that  gives  attachment  to 
the  appendix  there  may  be  no  pain,  or  the  pain 
may  not  be  intense,  and  because  of  this  lack  of  in- 
tensity, the  patient  tolerates  abuse  in  the  line  of 
drugging  and  feeding  until  an  abscess  forms,  the 
walls  of  which  surround  the  appendix  which  is 
inflamed  and  often  gangrenous.  About  this 
time,  on  account  of  the  gradual  increase  in  swell- 
ing, the  pressure  brings  obstruction,  partial  or 
complete,  causing  the  symptoms  to  become  sud- 
denly very  dangerous;  then  if  vigorous  examina- 


32  APPENDICITIS. 

tions  are  made  to  determine  the  exact  status  of 
the  disease,  don't  be  surprised  if  rupture  of  the 
pus  sac  takes  place!  This  then  demands  an  im- 
mediate operation  which  if  performed  will  show 
a  gangrenous  appendix  that  had  ruptured!  This 
is  quite  common  and  is  looked  upon  as  proof  posi- 
tive that  an  operation  was  justified;  in  fact,  the 
proper  and  only  thing  to  be  done,  and  it  should 
have  been  done  earlier! 

This  is  the  opinion  of  the  majority  of  the  pro- 
fession. It  really  appears  that  surgeons  are  in- 
nocent of  the  part  they  play  in  rupturing  unsus- 
pected abscesses  and  otherwise  complicating  this 
disease  by  much  rough  handling. 

The  paroxysmal  pain  which  is  characteristic 
of  the  early  stages  of  appendicitis  may  be  accom- 
panied by  fever,  sometimes  low  and  sometimes 
high,  nausea,  vomiting  and  diarrhea.  The  vomit- 
ing may  be  severe  and  there  may  only  be  nausea. 
If  there  is  much  vomiting  there  will  usually  not 
be  much  diarrhea  for  the  excessive  vomiting  is  an 
indication  that  there  is  obstruction.  In  other 
cases  there  is  both  nausea  and  diarrhea;  then 
the  obstruction  is  either  not  established,  for  the 
trouble  is  as  yet  a  local  inflammation  of  the 
mucous  membrane,  or  the  diarrhea  is  from  the 
bowels  below  the  cut-off. 

It  is  safe  to  prognose  obstruction  when  the 
vomiting  is  severe;  but  if  the  nausea  continues 
longer  than  three  days,  it  must  be  due  to  eating  or 


OBSTRUCTION.  33 

to  drugs,  to  taking  too  much  water  while  there  is 
nausea,  or  there  is  more  obstruction  than  can  be 
accounted  for  by  such  diseases  as  suppurative  in- 
flammation of  the  cecum  or  appendix. 

It  will  be  well  to  remember  that  diseases  of 
the  cecum  or  appendix  or  both  never  cause  com- 
plete obstruction,  except  in  exceedingly  rare  cases 
where  adhesive  bands  are  formed,  completing  the 
cut-off.    In  this  connection  it  will  be  well  to  also 
remember  that  in  absolute  obstruction  the  symp- 
toms of  nausea  and  vomiting,  or  retching,  will 
continue,  while  those  of  appendicitis  will  stop  in 
three  days.    In  addition  to  the  continued  nausea 
of  complete  obstruction,  the  pulse  grows  weaker 
and  more  frequent  and  the  patient  shows  great 
anxiety  of  expression,  there  is  a  sickness  that  can 
not  be  accounted  for  with  a  diagnosis  of  appen- 
dicitis or  typhlitis,  and  the  patient  has  the  appear- 
ance of  being  desperately  sick.     The  great  pain 
at  the  beginning  subsides,  the  temperature  falls, 
the  pulse  grows  rapid  and  weak,  the  skin  becomes 
leaky,  the  mind  becomes  dull,  drowsy  and  coma- 
tose, then  a  little  wandering  and  death  relieves 
the  suffering  in  a  short  time. 

These  symptoms  are  of  collapse  and  they  may 
come  on  in  the  course  of  a  typhoid  fever,  or  other 
diseases  of  the  alimentary  canal;  they  always 
mean  a  fatal  toxemia  either  from  obstruction  or 
perforation,  and  occasionally  the  only  forerunning 
symptom  is   sudden  abdominal    pain.      Circum- 


34  APPENDICITIS. 

stances  must  guide  in  making  a  diagnosis.  If, 
during  a  run  of  typhoid  fever,  there  should  be 
sudden  abdominal  pain  followed  with  symptoms 
of  collapse  and  nothing  to  account  for  it,  it  means 
perforation ;  an  immediate  operation  may  save  the 
patient ;  nothing  else  will. 

A  sudden  pain  in  the  abdomen  of  a  woman 
during  menstrual  life,  with  positively  no  unusual 
menstrual  symptoms  and  no  trouble  in  the  right 
ileo-cecal  region,  indicates  perforation  of  the 
stomach  or  of  the  gall-bladder.  If  there  have 
been  a  menstrual  period  or  two  gone  over  with  a 
slight  showing,  and  some  uneasiness,  perhaps 
nausea,  perhaps  a  flow  with  pain  somewhat  simu- 
lating abortion,  a  sharp,  severe  abdominal  pain 
followed  with  quickening  of  the  pulse  and  an  ex- 
ceedingly anxious  facial  expression,  ectopic  preg- 
nancy with  rupture  of  the  tube  may  be  suspected. 
One  must  also  keep  in  mind  renal  calculus  in  de- 
termining bowel  diseases. 

Authors  pretty  generally  unite  in  declaring 
that  appendicitis  is  a  dangerous  disease.  In  his 
late  book,  "The  Abdominal  and  Pelvic  Brain,' ' 
Dr.  Byron  Eobinson  of  Chicago  says,  "Appen- 
dicitis is  the  most  dangerous  and  treacherous  of 
abdominal  diseases — dangerous  because  it  kills 
and  treacherous  because  its  capricious  course  can 
not  be  prognosed.  *  *  *  For  years  I  have  made 
it  a  rule  to  recommend  appendectomy  to  patients 
having  experienced  two  attacks.    Fifty  per  cent. 


DR.  J.  B.   DEAVER.  35 

of  subjects  who  have  had  one  attack  experience  no 
recurrence. ' ' 

In  Keating 's  Cyclopedia  of  the  Diseases  of 
Children,  Dr.  John  B.  Deaver  of  Philadelphia 
makes  the  following  statements : 

"Appendicitis,  whether  acute  or  chronic,  is 
essentially  a  surgical  affection,  and  should  be 
placed  at  once  under  the  care  of  a  skilful  surgeon. 
The  truth  of  this  statement  is  becoming  recognized 
in  direct  proportion  to  the  general  knowledge  of 
the  course  and  uncertainties  of  the  disease,  and 
at  the  present  time  only  those  who  have  but  a  lim- 
ited idea  of  the  course  of  the  affection  and  have 
seen  but  a  few  cases,  attempt  to  treat  appendicitis 
without  the  advice  of  a  surgeon.' ' 

"Operation  is  the  only  procedure  by  which 
we  can  be  certain  of  curing  our  patient.  It  is  true 
that  some  cases  do  recover  from  an  attack  of  ap- 
pendicitis without  an  operation,  but  the  percent- 
age of  those  that  recover  from  the  disease  is  al- 
most nil." 

"The  main  reason,  however,  why  the  appen- 
dix should  be  removed  as  soon  as  possible  is  that 
no  one  can  state  positively  what  course  the  disease 
is  taking." 

"Although  a  strong  advocate  of  the  removal 
of  the  appendix  in  almost  every  case  of  inflamma- 
tion of  that  organ,  yet  there  are  a  few  conditions 
under  which  I  prefer  to  delay  operation.  When 
we  find  a   patient  with   persistent   vomiting,   a 


36  APPENDICITIS. 

leaky  skin,  a  rapid,  running  pulse,  a  diffuse  peri- 
tonitis and  signs  of  collapse,  I  believe  that  oper- 
ative interference  is  contraindicated.  Under  these 
conditions  an  operation  would  invariably  be  fol- 
lowed by  loss  of  life.  Ice  to  the  abdomen,  calomel 
pushed  to  free  purgation,  a  small  fly-blister  below 
the  ensiform  cartilage,  nutritious  enemata,  with 
stimulants  in  the  form  of  whiskey  or  champagne, 
and  hypodermics  of  strychnine,  give  a  more  hope- 
ful prospect  than  would  operation.  When  the 
peritonitis  has  subsided  and  the  constitutional 
condition  warrants,  operation  may  be  performed 
with  a  much  better  prognosis. ' ' 

The  symptoms  described  by  Dr.  Deaver  are 
those  of  collapse,  following  perforation,  diffuse 
peritonitis  to  be  followed  soon  by  death,  or  of 
narcotism — morphine  paralysis,  soon  to  be  de- 
scribed in  extenso  when  we  come  to  treatment. 

If  the  doctor  ever  had  a  patient  presenting 
those  symptoms  and  the  patient  lived  after  being 
subjected  to  the  treatment  he  recommends,  it  is 
safe  to  say  that  he  was  dealing  with  an  artificial 
collapse — a  drug  collapse — and  he  did  not  have 
perforation  and  diffuse  peritonitis. 

This  statement  of  the  eminent  Philadelphia 
surgeon  adds  another  very  weighty  proof  to  my 
oft-repeated  assertion  that  it  matters  not  how 
eminent  the  medical  man  may  be,  he  cannot  tell 
the  difference  between  drug  and  pathological 
symptoms.    Of  course  this  is  a  humiliating  state- 


SURGICAL  TREATMENT.  37 

ment,  and  it  is  not  expected  that  those  very 
eminent  medical  men  whom  I  charge  with  inabil- 
ity to  differentiate  between  drug  collapse  and  the 
collapse  due  to  disease,  will  acknowledge  that  I 
am  right,  for,  if  their  mental  horizons  extended 
far  enough  for  them  to  admit  it,  it  would  not  be 
necessary  for  me  to  say  it. 

In  no  other  way  can  the  atrocious  mistakes 
that  doctors  make  in  prognosis  be  accounted  for. 
How  many,  many  times  doctors  have  declared  that 
a  given  case  must  end  in  death,  and  they  are  so 
cocksure  that  they  are  right  that  they  leave  the 
patient  to  die;  some  sort  of  a  fake,  mountebank 
or  fanatic  comes  in,  the  drug  disease  wears  off 
and  in  a  few  days  the  patient  is  well.  That  is  ex- 
actly the  sort  of  a  case  Dr.  Deaver  describes.  The 
faker  gets  busy  with  drugs  that  antidote  the 
morphine  poisoning,  and  occasionally  a  patient 
gets  well  in  spite  of  all. 

In  regard  to  surgery  for  this  disease  I  shall 
quote  from  Ochsner: 

"Personally,  I  can  only  second  the  statement 
made  by  one  of  the  most  experienced  men  in  this 
country  in  the  surgical  treatment  of  appendicitis, 
that  there  are  thousands  of  surgeons  who  are 
otherwise  competent,  i.  e.,  competent  to  perform 
the  ordinary  surgical  and  gynecological  opera- 
tions, whom  he  would  not  think  of  permitting  to 
open  his  abdomen  in  case  he  personally  suffered 
from  an  attack  of  appendicitis.    This  condition  is 


38  APPENDICITIS. 

true  not  because  it  is  an  especially  difficult  or 
dangerous  operation,  but  because  it  requires  an 
appreciation  of  the  conditions  upon  which  success 
and  failure  depend,  and  this  appreciation  can  be 
obtained  only  by  observing  good  methods. 

"In  many  of  the  ordinary  surgical  operations 
it  is  not  necessary  to  follow  out  the  details  with 
any  great  degree  of  accuracy,  because  failure  to 
do  this  will  at  most  result  in  confining  the  patient 
to  bed  a  little  longer  than  usual  or  necessary, 
while  in  the  appendicitis  operation  it  is  likely  to 
result  in  the  death  of  the  patient. 

"This  position,  when  taken  in  the  discussion 
of  appendicitis  in  medical  societies,  has  frequent- 
ly given  rise  to  severe  criticism  because  upon  its 
face  it  looks  as  though  appendicitis  operations 
should  be  performed  only  by  the  few  who  happen 
to  have  acquired  especial  skill  in  this  class  of  surg- 
ery, possibly  at  the  expense  of  the  lives  of  a  num- 
ber of  patients. 

"This,  however,  is  not  the  case.  The  opera- 
tion is  simple  enough  if  one  will  but  take  the  pains 
to  learn  it,  and  every  town  of  five  thousand  in- 
habitants should  have  at  least  one  man  perfectly 
competent  to  do  such  work.  But  if  there  is  no 
such  man  available  then  I  would  say  most  em- 
phatically that  the  patient's  chances  of  recovery 
are  many  times  greater  with  proper  non-surgical 
treatment  than  with  an  operation.  Of  course,  pa- 
tients have  occasionally  recovered,  by  accident,  in 


DR.  OCHSNER.  39 

the  hands  of  most  incompetent  surgeons,  but  the 
death  rate  after  appendicitis  operations  in  the 
hands  of  incompetent  surgeons  is  absolutely 
frightful. 

"My  experience  and  personal  observation 
have  taught  me  that  physicians  and  surgeons,  as 
a  rule,  are  absolutely  conscientious,  and  that  when 
they  perform  this  operation,  notwithstanding  the 
fact  that  they  themselves  know  they  are  incom- 
petent (and  they  alone  must  necessarily  be  their 
own  judges  as  to  their  competency),  they  do  it  be- 
cause they  have  been  taught  that  this  is  the  only 
right  treatment,  and  that  the  patient  is  entitled 
to  an  effort  on  the  part  of  the  physician  or 
surgeon  to  save  the  life  which  is  in  danger.  I  be- 
lieve that  this  is  extremely  bad  teaching,  and  that 
many  hundreds  of  lives  have  been  sacrificed  un- 
necessarily on  account  of  this.  I  say  this  because 
I  am  confident  that  with  proper  non-operative 
treatment  almost  all  of  the  cases  which  are  diag- 
nosed reasonably  early  may  be  carried  through 
any  acute  attack,  no  matter  what  its  character 
may  be. 

"I  would  then  say,  primarily,  that  no  case  of 
appendicitis  should  be  operated  upon  unless  a 
competent  surgeon  is  available.  This,  of  course, 
does  not  apply  to  cases  in  which  a  circumscribed 
abscess  has  formed  which  anyone  can  open  with 
safety  provided  he  has  sufficiently  good  judgment 
not  to  do  anything  further. ' ' 


40  APPENDICITIS. 

Here  I  must  differ.  If  the  case  has  not  been 
complicated  by  overmuch  handling,  digging, 
punching,  thumping  and  otherwise  manipulating 
in  the  name  of  bimanual  diagnosis,  no  one  has  any 
right  to  put  a  knife  into  the  pus  sac  for  it  matters 
not  how  well  it  is  done  the  drainage  is  bad  and  is 
in  opposition  to  the  natural  outlet  through  the 
bowels.  Of  course  if  the  unfortunate  patient  has 
fallen  into  the  hands  of  some  one  who  believes  it 
the  prerogative  of  a  physician  to  manipulate  in 
season  and  out  of  season,  and  who  has  converted 
a  typhlitic  abscess  into  a  perityphlitic  one,  or 
forced  the  pus  to  burrow  towards  the  groin,  then 
a  free  opening  with  a  let-alone  after  treatment, 
except  thorough  drainage,  may  be  followed  in  time 
by  restoration  to  health;  however,  if  the  patient 
fully  recovers  it  will  be  more  from  luck  than  from 
the  usual  management. 


PATHOLOGY.  41 


CHAPTER  IV. 


Pathology :  Formerly  very  little  was  written 
about  the  pathology  of  the  appendix,  the  writers 
describing  more  the  lesions  of  the  cecum  and  sur- 
rounding structures.  After  the  birth  of  the  sur- 
gical craze,  the  exciting  cause  was  located,  or  sup- 
posed to  be  located  in  the  appendix,  and  the  ab- 
normal condition  of  the  cecum  was  and  is  consid- 
ered to  be  secondary  or  due  to  the  lesions  found 
in  the  appendix.  The  profession  must  evolve  be- 
yond its  present  tendency  to  look  for  cause  in  the 
organ.  First  understand  the  general,  then  the 
special  will  be  apparent. 

The  pathology  of  the  appendix  has  now  grown 
exceedingly  voluminous,  and  if  it  were  as  valuable 
in  quality  as  it  is  great  in  quantity  the  necessity 
for  more  investigation  would  be  removed. 

Appendicitis  means  inflammation  of  the  ap- 
pendix. This  inflammation  may  affect  the  whole 
structure  or  merely  a  part.  Catarrhal  appen- 
dicitis affects  only  the  mucous  membrane. 

The  appendix  may  be  gangrened,  wholly  or 
in  part.  At  times  only  the  mucous  membrane  is 
gangrenous.  The  mucous  membrane  may  be 
ulcerated  and  the  pus  penned  in  because  of  a  clos- 
ure of  the  mouth  from  swelling. 


42  APPENDICITIS. 

Concretions  are  found  in  the  organ  at  times. 
These  are  evidently  formed  inside  the  appendix, 
for  they  are  often  too  large  to  enter  in  the  form 
in  which  they  are  found. 

When  there  is  perforation  of  the  appendix 
the  result  is  peritonitis  according  to  some  authors, 
and,  according  to  others  just  as  great,  this  is  dis- 
puted.   I  belong  to  the  latter  class  in  belief. 

The  pathology  of  appendicitis  is  necessarily 
touched  upon  more  or  less  in  going  over  the  eti- 
ology, symptoms,  and  treatment  of  the  disease, 
and  variation  is  the  rule,  for  how  could  it  be  other- 
wise when  subject  and  environment  must  always 
vary? 

As  soon  as  an  inflammation  starts,  the  first 
thing  that  nature  does  is  in  the  line  of  enforcing 
the  first  law  of  cure,  namely :  rest.  To  bring  this 
about  the  musculature  is  set,  rigidly  contracted, 
thus  fixing  the  parts.  The  contraction,  of  course, 
will  be  in  keeping  with  the  irritation  of  the  parts ; 
great  pain  means  great  rigidity,  and  vice  versa. 
This  being  true,  the  harm  that  must  come  from 
keeping  the  stomach  and  bowels  irritated  by  giv- 
ing drugs  and  food  should  be  plain  to  any  mind 
capable  of  reasoning  and  willing  to  think. 

The  more  food  given  the  more  gas,  pain  and 
rigidity,  and  the  more  rigidity  the  more  complete 
the  obstruction,  and  the  more  complete  the  ob- 
struction the  more  retention  of  gas.    I  need  not 


FOOD  DOES  HARM.  43 

enumerate  the  evils  due  to  gas  distention,  for  they 
should  be  apparent. 

If  the  obstruction  caused  by  the  swelling  in- 
cidental to  the  hyperemia  and  inflammation  is  not 
already  complete,  the  fixing  or  muscular  rigidity 
completes  it.  After  the  obstruction  is  complete, 
if  there  is  diarrhea,  which  is  frequently  one  of  the 
first  symptoms,  it  comes  from  below  the  cut-off. 

The  inflammation  of  the  cecum  and  appendix 
is  similar  to  inflammations  elsewhere;  the  capil- 
lary blood  vessels  become  engorged,  the  circulation 
becomes  sluggish,  and  this  causes  swelling;  the 
tissues  then  grow  dark  from  the  congestion.  This 
condition  is  similar  to  tumefaction  in  general, 
which  is  favorable  to  abscess  formation. 

When  the  local  irritation  and  inflammation 
start  with  enough  impetus  to  evolve  an  abscess 
the  parts  become  fixed,  as  stated  above,  and  the 
environing  structures  assume  an  attitude  of  al- 
ligated  defense.  There  is  a  drawing  together  of 
neighboring  tissue ;  the  omentum,  which  should  be 
recognized  as  the  brood  mother  and  care-taker  of 
everything  vital  in  the  abdominal  cavity,  joins 
with  contiguous  structures  and  all  become  welded 
together  by  a  friendly  adhesive  inflammation. 
When  this  defense  is  complete  the  abscess  is 
walled  in  so  completely  and  with  such  thorough- 
ness that  all  possibility  of  intraperitoneal  rupture 
rests  with  the  blundering,  heavy-handed,  trouble- 
hunting  profession;  and  if  nature  ever  fails  to 


44  APPENDICITIS. 

complete  the  building  of  this  wall  of  defense  it  will 
be  because  she  has  been  interfered  with  by  of- 
ficious meddling  in  the  name  of  scientific  healing. 

There  is  no  question  but  that  many  of  these 
patients  are  seriously  handicapped  and  others 
positively  killed  by  unskilful,  overzealous,  super- 
fluous examinations.  A  heavy-handed  attendant 
should  never  be  allowed  to  manipulate  swellings  in 
the  right  iliac  fossa,  nor  in  any  other  suspected 
region,  for  fear  of  destroying  nature's  defenses, 
and  possibly  rupturing  an  abscess,  the  contents  of 
which  will  be  emptied  into  the  peritoneal  cavity, 
causing  peritonitis  and  death. 

Seeds  are  seldom  found  in  the  appendix  and 
the  fear  of  swallowing  them  because  they  may 
lodge  in  it  is  not  well  founded.  There  is  no  ques- 
tion but  that  this  organ  has  the  power,  when  nor- 
mal, of  taking  care  of  itself.  It  has  a  peristaltic 
action  and  can  expel  anything  that  is  capable  of 
gaining  entrance. 


SYMPTOMS.  45 


CHAPTER  V. 

Symptoms:  An  acute  attack  is  ushered  in 
with  severe  pain.  At  first  this  is  felt  over  the 
entire  abdomen,  but  it  is  more  marked  near  the 
navel  than  elsewhere.  After  about  twenty-four 
hours  it  becomes  localized  in  the  region  of  the 
cecum. 

The  pain  is  colicky  or  spasmodic  in  character, 
showing  that  it  is  due  to  peristalsis;  food  of  any 
kind  increases  the  peristalsis;  hence  the  pain  be- 
comes more  severe  after  feeding.  Do  not  make 
the  mistake  of  thinking  that  liquid  food,  such  as 
milk,  can  be  given,  for  a  teaspoonful  is  sometimes 
sufficient  to  make  the  patient  miserable  for  a  whole 
day. 

The  abdomen  is  tender,  especially  over  the 
cecum,  and  should  therefore  be  manipulated  as 
little  as  possible,  for  it  causes  the  patient  unnec- 
essary pain,  and  if  an  abscess  has  formed  there 
is  danger  of  breaking  the  walls  which  nature  has 
thrown  up. 

Nature  's  tendency  appears  to  be  to  fix  the  in- 
flamed portion  so  as  to  secure  rest  and  this  is  ac- 
complished by  the  muscles  of  the  abdominal  wall 
becoming  rigid,  especially  over  the  cecum.  These 
muscles  are  contracted  to  such  an  extent  that  the 


46  APPENDICITIS. 

right  thigh  is  often  drawn  up  in  order  to  relieve 
the  tension. 

When  the  cecum  is  inflamed  it  is  common  for 
the  colon  to  be  loaded;  this  colon  obstruction  pre- 
vents the  onward  passage  of  the  contents  of  the 
small  intestine,  and  when  they  cannot  free  them- 
selves and  the  peristaltic  movements  meet  with 
sufficient  obstruction  to  force  a  halt,  the  pain  and 
suffering  become  intense.  When  the  peristaltic 
movement  has  met  with  a  few  disappointments  it 
reverses  and  empties  the  contents  of  the  small  in- 
testine into  the  stomach.  The  result  is  nausea 
and  vomiting  which  at  times  are  both  severe  and 
persistent.  But  when  it  lasts  beyond  three  days 
it  is  an  indication  of  a  complication  or  mistake 
in  diagnosis,  providing  the  patient  has  been  prop- 
erly treated. 

The  abdomen  becomes  distended  with  gas  if 
drugs  and  food  are  given;  as  regards  the  pulse, 
there  is  nothing  characteristic  about  the  pulse 
rate  and  the  temperature  in  this  disease.  Some- 
times the  temperature  does  not  go  over  100°  F., 
but  at  times  it  reaches  105°  F.  The  pulse  is  some- 
times so  rapid  that  it  is  hard  to  count — due  usual- 
ly to  drug  influence — and  again  it  may  not  go 
above  100  or  110  beats  per  minute  during  the  en- 
tire attack. 

As  these  patients  are  nearly  always  consti- 
pated, and  suffering  from  indigestion,  they  gen- 
erally have  a  coated  tongue. 


CARDINAL  SYMPTOMS.  47 

The  above  symptoms  are  those  relied  upon  in 
making  a  diagnosis,  and  especially  the  first  four — - 
pain,  tenderness,  rigidity,  and  nausea  with  vomit- 
ing— which  are  generally  referred  to  as  the  four 
cardinal  symptoms.  Some  authors  give  a  "  char- 
acteristic triad, "  namely:  pain  with  tenderness  of 
the  abdominal  wall,  fever,  and  vomiting. 

A  patient  may  have  pain  with  tenderness, 
fever  and  vomiting,  and  be  very  far  from  having 
appendicitis.  There  is  a  world  of  difference  in  the 
importance  of  pain,  the  range  being  from  no  dan- 
ger at  all  to  absolutely  no  hope.  Tympanites  may 
mean  a  very  simple  state  or  an  absolutely  hopeless 
state.  To  be  able  to  interpret  the  exact  worth  of 
symptoms  means  observation,  study,  reflection — 
labor  and  experience  running  over  years — and  a 
love  of  work  that  is  not  the  good  fortune  of  a  very 
large  percentage  of  mankind. 

Before  we  get  through  with  this  subject  the 
reader  will  be  shown  how  it  is  possible  for  highly 
educated  men  to  be  wholly  unable  to  interpret  the 
worth  of  symptoms. 


48  APPENDICITIS. 


CHAPTER  VI. 

Surgical  Treatment:  Appendicitis  is  quite 
generally  thought  of  as  an  exclusively  surgical 
disease.  Osier  recommends  that  such  cases  be 
operated  upon,  and  most  of  the  prominent  physi- 
cians agree  with  him.  The  surgeons  are  a  unit  for 
the  operative  treatment. 

Many  surgeons  are  in  accord  with  Prof.  L.  E. 
Eussell  of  Cincinnati,  O.,  namely,  that  it  is  not  a 
question  of  "when  to  operate,  but  how  much  to 
operate,' '  meaning  that  all  cases  should  be  op- 
erated upon  as  soon  as  possible  after  the  diagnosis 
has  been  made,  but  the  extent  of  the  operation  is 
to  be  decided  by  the  conditions  found  after  the  in- 
cision has  been  made.  If  the  appendix  is  sur- 
rounded with  pus  and  hard  to  get  at,  the  indication 
is  merely  for  drainage  at  this  operation,  but  if 
the  appendix  is  accessible,  it  should  be  removed. 

Ochsner  recommends  the  withdrawal  of  all 
food  by  mouth,  washing  out  the  stomach,  leeches 
to  be  applied  on  the  abdomen  over  the  inflamma- 
tion to  relieve  pain,  rectal  feeding,  and  operation 
in  every  case  after  the  acute  attack  is  over.  If  a 
"competent  surgeon' '  is  available  he  thinks  the 
proper  thing  to  do  is  to  operate  during  the  acute 
attack,  except  in  a  class  of  very  severe  cases, 
which,  he  says,  have  a  better  chance  to  recover 


SURGICAL  TREATMENT.  49 

without  the  operation.  I  will  quote  a  few  para- 
graphs from  his  book,  setting  forth  his  views : 

"Taking  into  consideration  the  pathological 
conditions  described,  together  with  the  clinical  ex- 
perience, the  likelihood  of  a  recurrence  after  an 
attack  if  no  operation  is  performed,  and  the  like- 
lihood of  a  complete  and  permanent  recovery  if 
the  diseased  organ  is  removed  under  favorable 
circumstances,  we  can  come  to  but  one  conclusion, 
namely,  that  if  the  desired  condition  can  be  ob- 
tained the  diseased  appendix  should  be  removed." 

"  Except  in  very  rare  cases  in  which  the  en- 
tire mucous  membrane  of  the  appendix  is  de- 
stroyed during  the  first  attack,  it  is  doubtful 
whether  the  patient  ever  completely  recovers  un- 
less the  appendix  be  removed.  It  is  more  likely, 
from  an  anatomical  and  pathological  standpoint, 
and  certainly  more  in  accordance  with  my  clinical 
observations,  that  the  patient  usually  suffers  from 
disturbance  of  his  digestive  apparatus  after  recov- 
ering from  an  acute  attack  of  appendicitis. ' ' 

"Mynter  does  not  deny  the  possibility  of  com- 
plete recovery  from  appendicitis  without  remov- 
ing the  organ,  but  considers  it  an  exception  or 
almost  an  impossibility,  and  I  find  that  this  view 
is  shared  by  a  majority  of  clinical  observers  of 
wide  experience. ' ' 

"It  is  rare  for  an  acute  attack  of  appendicitis 
to  subside  unoperated  without  leaving  one  or  more 
of  the  pathological    conditions    briefly    described 


50  APPENDICITIS. 

above,  and  it  is  plain  that  with  these  present  the 
patient  must  be  much  more  liable  to  a  future  at- 
tack than  he  was  primarily.  In  fact,  many  of  the 
best  observers  with  the  largest  experience  think 
that  recurrence  in  these  cases  is  the  rule  and  com- 
plete recovery  the  rare  exception. " 

[The  pathological  conditions  referred  to  are 
ulcerated  or  gangrened  appendix,  perforations, 
fecal  concretions  in  the  appendix,  etc.] 

"It  does  not  matter  whether  the  patient  suf- 
fers from  catarrhal  appendicitis,  with  or  without 
a  foreign  body  in  the  appendix,  or  whether  the  ap- 
pendix be  gangrenous  or  perforated,  he  will  al- 
most invariably  recover  if  from  the  beginning  of 
the  disease  absolutely  no  food  is  given  by  mouth. ' ' 

' '  Some  years  ago,  before  I  had  learned  to  ap- 
preciate the  treatment  which  I  now  describe,  I 
frequently  operated  upon  patients  in  just  this  con- 
dition, [condition  of  patient  described  as  having 
temperature  of  104°  F.,  pulse  140,  abdomen  very 
much  distended,  features  pinched  and  patient 
delirious],  as  a  last  resort,  thinking  that  this  gave 
them  the  only  possible  chance  of  recovery.  Since 
then  I  have  learned  that  this  case  belonged  to  a 
class  which  practically  never  recovered  after  an 
operation,  if  it  is  done  while  the  condition  is  that 
in  which  I  found  this  patient,  and  of  which  a  very 
large  majority  recover  if  the  treatment  is  fol- 
lowed which  I  have  described." 


SEVERE  CASES.  51 

[The  treatment  referred  to  is  to  let  the  pa- 
tient alone  except  giving  food  by  rectum.] 

"I  have  had  an  opportunity  to  observe  a  very 
large  number  of  these  patients  under  this  form 
of  treatment,  and  have  operated  upon  many  of 
them  at  various  intervals  after  the  acute  attack 
through  which  they  were  treated  in  this  manner, 
and  have  been  able  to  demonstrate  that  the  pa- 
tient can  recover,  and  practically  always  does  re- 
cover, if  this  method  of  treatment  is  employed.  Of 
course,  one  occasionally  encounters  a  patient  suf- 
fering from  appendicitis  who  is  in  a  dying  con- 
dition, and  then  neither  this  nor  any  other  method 
is  of  any  value. ' ' 

"I  find  that  many  authors  advise  rectal  feed- 
ing under  certain  conditions,  but  I  am  certain  that 
the  exclusive  rectal  alimentation  is  of  greater  im- 
portance in  the  treatment  of  appendicitis  than  any 
other  single  method,  but  I  am  equally  certain  that 
it  must  be  carried  out  thoroughly,  because  even  a 
small  amount  of  food  or  the  administration  of  a 
cathartic  may  suffice  to  bring  about  a  fatal  issue." 

[Why  feed?  There  is  no  danger  of  starv- 
ing !] 

"lam  also  certain  that  many  patients  are 
enormously  benefited  by  the  use  of  gastric  lavage 
for  the  purpose  of  removing  a  quantity  of  decom- 
posing material,  the  absorption  of  which  would 
certainly  do  a  great  amount  of  harm.  I  am  also 
certain  that  gastric  lavage  does  permanent  good 


52  APPENDICITIS. 

only  if  no  further  food  is  placed  into  the  stomach, 
which  would  result  in  further  decomposition." 

[At  the  beginning  of  treatment — the  first  visit 
— wash  the  stomach  and  then  feed  no  more. 

Although  some  physicians  boast  that  this  is 
an  age  of  preventive  medicine,  the  following  para- 
graph is  about  all  that  is  devoted  to  this  phase  of 
the  subject.  In  one  or  two  places  people  are  cau- 
tioned not  to  eat  too  much  and  chew  thoroughly, 
but  what  does  this  amount  to?  How  many  people 
know  how  much  to  eat  or  how  thoroughly  to  chew? 
Very  few  physicians  have  a  grasp  of  this  sub- 
ject.] 

"It  is  true  that  recurrences  can  usually  be 
prevented  by  careful  attention  to  diet,  by  securing 
daily  free  evacuations  of  the  bowels,  by  avoiding 
over-work  and  above  all  things  by  abstaining  from 
eating  too  freely,  especially  of  indigestible  food 
when  tired.  Notwithstanding  these  facts  most  pa- 
tients will  never  be  entirely  well  after  recovering 
from  an  attack  of  appendicitis,  and  if  this  is  the 
case  I  believe  that  the  best  treatment  consists  in 
the  removal  of  the  diseased  appendix. '  ' 

"In  conclusion  I  will  say  that  the  most  im- 
portant lesson  my  experience  has  taught  me  is  the 
fact  that  more  harm  is  done  to  the  patient  suffer- 
ing from  acute  appendicitis  by  the  administration 
of  any  kind  of  nourishment  or  cathartics  by  mouth 
than  in  any  other  way,  and  that  more  lives  can 
be  saved  by  prohibiting  this  and  by  removing  any 


RECURRENCES.  53 

food  which  may  be  in  the  stomach  at  the  beginning 
of  the  attack  by  gastric  lavage  than  by  all  the 
other  methods  of  medical  and  surgical  treatment 
combined. ' ' 

[This  is  my  belief  and  treatment  and  has  been 
since  I  began  to  practice  my  profession.] 

The  above  extracts  were  taken  from  Dr. 
Ochsner's  Monograph  on  Appendicitis. 

When  a  patient  has  completely  recovered 
from  appendicitis  he  should  learn  to  live  correct- 
ly. Learn  to  eat  properly  and  to  know  how  to 
take  care  of  the  body  in  every  way. 

There  is  much  to  learn  on  the  subject  of  what 
to  eat,  what  not  to  eat,  what  foods  to  combine  and 
what  combinations  to  shun,  when  to  eat,  when  not 
to  eat,  etc. 

Appendicitis  is  caused  by  wrong  eating ;  those 
who  go  through  the  disease  and  recover,  will  have 
another  attack  unless  they  change  their  style  of 
eating. 


54  APPENDICITIS. 


CHAPTER  VII. 

Treatment:  I  believe  that  contrasting  treat- 
ments is  the  very  best  way  to  teach ;  however,  this 
plan  is  not  so  good  when  carried  on  in  writing  as 
it  would  be  clinically. 

In  order  to  contrast  my  treatment  with  the 
best  jnst  now  available  I  shall  quote  from  one  of 
the  latest  authorities,  "  Modern  Clinical  Medicine 
— Diseases  of  the  Digestive  System."  Edited  by 
Prank  Billings,  M.  D.,  of  Chicago.  An  authorized 
translation  from  "Die  Deutsche  Klinik"  under 
the  general  editorial  supervision  of  Julius  L. 
Salinger,  M.  D.  Published  by  D.  Appleton  and 
Company,  1906. 

It  is  reasonable  to  believe  that  when  one  of 
our  leading  American  physicians  thinks  enough 
of  a  foreign  author  to  translate  his  productions 
the  material  must  be  pretty  well  up  to  the  top  of 
medical  literature,  and  that  is  my  only  reason  for 
selecting  this  particular  contribution  on  which  to 
make  my  comments  for  the  purpose  of  contrast. 

The  case  I  select  is  strictly  in  line  and  par- 
allels a  case  of  my  own.  It  is  a  case  of  Diffuse 
and  Circumscribed  Peritonitis,  treated  and  re- 
ported by  0.  Vierordt,  M.  D.,  of  Heidelberg. 

"Acute,  Diffuse  Peritonitis:  As  an  introduc- 
tion to  the  discussion  of  our  present  views  of  acute 


DR.  VIERORDT'S  CASE.  55 

peritonitis    I   will    relate    the    following    clinical 
history : 

"Case  1. — A  previously  healthy  merchant, 
aged  31,  was  taken  ill  after  a  few  days  of  vague, 
dull  pain  in  the  right  side  of  the  abdomen  which 
he  had  disregarded,  and  upon  the  20th  of  October, 
about  midday,  he  was  seized  with  very  severe  pain 
in  the  right  lower  abdominal  region  which  com- 
pelled him  to  seek  his  bed ;  soon  afterward  he  had 
chilly  sensations  which  increased  to  marked  chills ; 
there  was  also  nausea,  eructation  and  vomiting, 
first  of  food  and  then  of  bilious  mucus;  a  little 
later  tenesmus  appeared,  the  patient  first  voiding 
small,  compact  feces,  followed  by  scant,  thin  de- 
jecta. Within  a  few  hours  the  abdomen  had  be- 
come tympanitic,  the  pains  continued  with  ex- 
acerbations upon  motion,  after  eructations,  and 
on  talking ;  the  entire  abdomen  was  very  sensitive. 
Strangury  with  the  frequent  discharge  of  scant 
urine  was  observed. 

"Toward  evening  the  physician  found  the  pa- 
tient extremely  ill,  immovable  in  the  active  dorsal 
decubitus,  with  an  anxious  facial  expression,  red- 
dened cheeks,  cautious,  superficial  respiration  with 
a  low,  hushed  voice ;  he  complained  of  continuous, 
also  occasionally  of  marked  tearing  and  contract- 
ing, pains  in  the  entire  abdomen,  most  severe 
upon  the  right  side  low  down ;  the  temperature  was 


56  APPENDICITIS. 

103.2°  F.,  the  pulse  was  112,  full,  somewhat  tense, 
regular  and  even. 

"The  lips  were  dry,  the  tongue  markedly 
coated;  foetor  ex  ore  was  present;  painful  eructa- 
tions were  frequent,  also  singultus,  complete  an- 
orexia and  extreme  thirst.  The  respirations  were 
superficial,  quite  rapid,  and  purely  thoracic;  the 
diaphragm  was  slightly  raised;  the  pulmonary- 
liver  border  was,  in  the  right  mammillary  line,  at 
the  lower  border  of  the  fifth  rib ;  upon  anterior  ex- 
amination the  thoracic  organs  appeared  normal; 
the  examination  of  the  back  was  not  then  under- 
taken. 

"The  entire  abdomen  was  uniformly  tymp- 
anitic, everywhere  very  sensitive  to  the  slightest 
pressure,  but  more  so  upon  the  right  side  than 
upon  the  left.  There  was  also  pain  upon  pressure 
in  the  lumbar  region. 

"Signs  of  abdominal  respiration  were  absent. 
Careful  palpation  showed  a  uniform,  drum-like  re- 
sistance, otherwise  nothing  abnormal.  The  per- 
cussion note  over  the  abdomen  upon  light  tapping 
(and  only  this  could  be  borne)  revealed  no  de- 
cided difference,  and  nowhere  any  dullness;  upon 
prolonged  continued  auscultation,  high-pitched  in- 
testinal murmurs  were  here  and  there  heard. 

"Eetraction  of  the  thighs  produced  diffuse 
abdominal  pain,  more  marked  upon  the  right  side 


PERITONITIS.  57 

than  upon  the  left;  careful  examination  of  the 
hernial  rings  gave  a  negative  result. 

"Upon  careful  digital  exploration  per  rectum 
in  the  dorsal  decubitus,  nothing  abnormal  was 
noted  except  pain  in  the  floor  of  the  pelvis;  the 
rectum  was  empty. 

"Since  morning  neither  feces  nor  flatus  had 
been  passed ;  the  patient  complained  of  strangury 
which,  however,  he  rarely  attempted  to  relieve  be- 
cause he  feared  to  aggravate  the  pain  which  shot 
downward  and  radiated  into  the  urethra.  The 
urine  was  of  high  color,  clear,  and  contained  a 
trace  of  albumin  and  large  amounts  of  indican. 

"The  physician  in  charge  of  the  case  diagnos- 
ticated acute,  diffuse  peritonitis,  the  origin  of 
which  was  not  quite  clear;  very  likely  it  was  in 
the  appendix.  He  ordered  absolute  rest,  that  the 
urine  and  feces  be  voided  in  the  recumbent 
posture ;  that,  for  the  present,  only  small  quanti- 
ties of  ice  be  taken  by  the  mouth ;"  [First  mistake. 
Never  use  ice  nor  ice  water  to  relieve  thirst  for 
it  creates  an  unquenchable  thirst  and  causes  nerv- 
ousness and  general  discomfort,  not  only  in  this 
disease  but  in  all  others.]  "that  two  bags  filled 
with  ice  be  applied  to  the  abdomen,  and  be  sus- 
pended from  a  hook  if  they  could  not  be  borne  di- 
rectly upon  the  abdomen.  Furthermore,  at  first 
every  two  hours,  later  somewhat  less  frequently, 
0.03  of  opium  purum  in  powder  form  was  to  be 


58  APPENDICITIS. 

taken  in  a  little  water.' '  [Pure  opium  0.03  or 
6/13  grain  every  two  hours  at  first,  less  frequently 
later,  was  the  second  mistake,  for  opium  brings 
on  general  depression.  It  not  only  dulls  sensa- 
tion, but  it  inhibits  combustion  thereby  lessening 
nerve  supply,  weakens  the  heart  action,  and  masks 
the  physiological  as  well  as  the  pathological  state. 
The  disadvantages  of  such  an  influence  should  be 
apparent  to  even  a  medical  novice.  The  influence 
of  opium  in  inhibiting  nerve  supply  reduces  the 
normal  irritability — muscular  tone;  this  works  a 
great  disadvantage  in  bringing  about  a  tympanites 
entirely  out  of  keeping  with  the  intensity  of  the 
disease  and  this  is  not  the  only  artificial  symptom 
induced  by  this  drug  as  we  shall  see  later. 

An  opium  tympanites  causes  many  physicians 
to  mistake  it  (a  drug-action,  or  a  symptom  induced 
by  drug-action)  for  the  tympanites  caused  by  peri- 
tonitis. The  great  disadvantage  of  thus  masking 
and  perverting  symptoms,  which  should  be  nat- 
ural so  that  the  physician  can  know  at  any  hour 
of  the  day  just  exactly  where  his  patient  is,  must 
certainly  present  itself  even  to  a  lay  mind. 

It  surely  is  important  to  know  that  an  opium- 
induced,  phantom  peritonitis  causes  pressure 
upon  the  diaphragm,  which  in  turn  crowds  the 
lungs  and  heart,  inducing  precordial  oppression — 
smothering  sensations  and  simulating  important 


OPIUM  SYMPTOMS.  59 

symptoms  which  should  be  understood  at  once  so 
that  a  proper  remedy  may  be  applied.] 

"In  the  following  forty-eight  hours,  with  ir- 
regular variations  and  a  slight  tendency  to  rise, 
the  temperature  ranged  between  102.2°  F.,  and 
105.3°  F.  The  pulse  became  more  frequent  but 
remained  strong  and  uniform;  the  respirations 
were  unaltered  in  character  but  increased  in  fre- 
quency to  48. ' '  [Unnatural  and  brought  about  by 
opium.]  "The  patient,  unless  under  the  influence 
of  opium,  was  sleepless,  his  mind  was  clear,  and 
he  gave  the  impression  of  being  extremely  ill,  al- 
though not  in  collapse."  [This  is  peculiar  to 
opium;  it  was  too  early  for  these  symptoms  to 
develop  in  this  case;  hence  drugs  brought  them 
on.]  "The  pains,  eructations  and  vomiting  were 
decidedly  relieved  by  the  opium ; ' '  [A  relief  that 
was  bought  at  a  tremendous  cost,  for  a  time  came 
in  a  very  few  days  when  it  was  hard  to  tell 
whether  the  vomiting  was  from  the  disease  or 
from  the  drug.  The  increase  in  respirations  was 
due  to  opium.]  "but  ice-bags  for  a  time  were  not 
well  borne  and  cold  Priessnitz  compresses  were 
substituted.  Vomiting  was  rare,  was  invariably 
bilious  and  coarse-grained ;  neither  feces  nor  flatus 
were  discharged;  the  urine  was  as  before  the 
diazo-reaction  negative. 

"Distention  of  the  abdomen  and  the  area  of 
diffuse    resistance    increased;    sensitiveness    to 


60  APPENDICITIS. 

touch  appeared  to  be  dulled  by  the  opium ;  in  the 
ileo-cecal  region,  however,  it  was  constantly  severe 
and  lancinating.  The  liver  dullness  below  de- 
creased ;"  [Why  not?  Extending  tympanites 
caused  it — insignificant  at  most.]  "the  pulmonary- 
liver  border  extended  to  the  upper  border  of  the 
fifth  rib ;  on  the  right  side  of  the  abdomen  between 
the  navel  and  the  anterior,  superior  spine  of  the 
ilium  a  circumscribed  slight  dullness  was  ob- 
served.' '  [This  could  have  been  taken  for  granted 
without  unnecessary  palpation.]  "There  was 
great  nausea  and  burning  thirst."  [Already  the 
opium  was  getting  in  its  work.  Great  nausea  and 
burning  thirst  were  not  due  to  the  disease,  and 
the  crowding  upward  of  the  liver  border  was 
caused  by  the  gas  distention.] 

"Diagnosis:  Acute  diffuse,  appendicular  per- 
itonitis, probably  also  perforation;  circumscribed 
perityphlitic  abscess.' '  [The  diffuse  peritonitis 
was  apparent  to  the  eye  but  not  to  the  reason  as 
the  course  of  the  disease  proves  before  many 
days.] 

"Operation  was  considered  but  not  per- 
formed. Removal  to  the  hospital  for  the  purpose 
of  an  operation  was  absolutely  declined  by  the 
patient. 

"I  saw  him  upon  the  following  day,  the  fourth 
of  the  disease.' '  [Undoubtedly  this  case  had  ad- 
vanced to  the  seventh  day  when  the  description 


NARCOTISM.  61 

began.]  "In  general  the  severity  of  the  clinical 
picture  had  increased,  especially  some  of  the  in- 
dividual symptoms :  Severe,  markedly  febrile  gen- 
eral condition;  pulse  120  to  136,  moderately  full, 
regular. "  [Drugs  and  food  caused  the  increase 
in  the  severity  of  the  symptoms,  for  if  the  increase 
in  pulse  and  temperature  had  been  due  to  toxic 
infection,  there  would  have  been  no  amelioration 
of  these  symptoms,  which  we  find  takes  place 
later.]  "There  was  insomnia  with  occasional 
opium  slumber ;  otherwise  the  mind  was  clear  but 
anxious.  The  tongue  was  thickly  coated,  the  lips 
were  dry,  there  was  tormenting  thirst.' '  [Ice 
and  opium  were  getting  in  their  work,  increasing 
the  nervousness  and  of  course  the  fever.]  "The 
cheeks  were  red.  The  patient  maintained  the 
dorsal  decubitus  with  feebly  flexed  legs  and 
hushed  voice;  the  hands  moved  but  slightly  and 
trembled."  [Narcotism.]  "Occasionally  there 
were  spontaneous  attacks  of  severe,  tearing,  ab- 
dominal pain,  starting  posteriorly  in  the  lower 
right  side."  [Why  not?  Food  was  being  given, 
stimulating  peristalsis.]  * '  The  abdomen  was  very 
tympanitic  and  tense,  and  could  scarcely  be 
touched ;  nevertheless,  it  was  possible  to  determine 
upon  the  right  side  low  down  an  area  of  dullness 
about  the  size  of  a  hand  with  increased  resistance ; 
otherwise  the  note  was  tympanitic  upon  percus- 
sion."    [The  reader  will  notice  the  frequency  of 


62  APPENDICITIS. 

the  reports  regarding  the  area  of  dullness  and  ex- 
tension of  tympanites.  These  frequent  examina- 
tions are  wearing  on  patients  in  this  condition, 
and  are  of  no  consequence  whatever ;  they  start  at 
nothing  and  end  nowhere,  except  in  the  discom- 
fort and  often  the  death  of  the  patient;  they  are 
practiced  by  too  many  physicians  and  should  be 
discouraged  for  they  represent  a  very  bad  habit 
and  are  harmful;  they  are  pushed  to  a  pernicious 
extent  in  some  cases,  for  without  doubt  abscesses 
are  ruptured  by  them.  If  the  physicians  were  not 
satisfied  by  this  time  without  the  need  of  laying 
on  of  hands,  observation  and  analysis  were  lack- 
ing.] 

"The  diaphragm  was  raised;  except  for  a 
small  zone  liver  dullness  was  absent."  [Of  what 
possible  benefit  was  this  knowledge  under  the  cir- 
cumstances?] "Now  and  then  there  was  grass- 
green  vomitus  which,  the  last  time,  contained  a 
few  brownish  granules  and  had  a  fecal  odor. 
Urine  unchanged;  micturition  very  painful;  no 
feces.' '  [Proof  positive  that  there  was  no  peri- 
tonitis yet,  and  the  indicating  symptoms  were 
those  of  opium.] 

"Opium  at  first  decidedly  influenced  the  con- 
dition; the  patient  took  daily  0.5  to  1.8,  and  since 
yesterday  morphin  subcutaneously  0.02  at  a 
dose. "  [Of  course,  anyone  acquainted  with  opium 
knows  that  it  loses  its  effect,  but  it  never  fails  to 


PROFESSIONAL  OFFICIOUSNESS.  63 

do  its  damage.    The  daily  intake  of  7%  grains  to 
27.5  grains  must  lead  to  trouble.] 

"Ice  bags  were  not  well  borne,  and  Priessnitz 
compresses  were  used  continuously.  The  intake 
of  food  was  reduced  to  almost  nothing. "  [Not 
one  teaspoonful  of  food  should  have  been  given; 
under  such  treatment  this  case  would  have  been 
very  comfortable.  Foods  and  drugs  were  the 
cause  of  the  discomfort.] 

"With  a  sharply  circumscribed  perityphlitic 
abscess  there  could  be  no  doubt  of  the  diagnosis 
of  diffuse  peritonitis  nor  of  the  indication  for  op- 
eration on  account  of  the  long  continuance  of  the 
severe  symptoms.  But  neither  this  proposition 
nor  that  of  an  exploratory  laparotomy,  the  result 
of  which  might  have  induced  the  patient  to  yield, 
was  accepted.' '  [It  is  an  evidence  of  professional 
officiousness  to  say  positively  that  there  was  a 
"sharply  circumscribed  perityphlitic  abscess." 
How  was  it  possible  with  meteorism  as  described, 
to  say  that  there  was  a  sharply  circumscribed  per- 
ityphlitic abscess  ?  It  was  tacitly  assuming  a  diag- 
nostic skill  that  must  test  the  strength  of  every 
American  physician's  credulity  to  the  utmost.  The 
long  continuance  of  the  severe  symptoms  was  no 
fault  of  the  disease.  The  worst  case  should  be 
made  comfortable  in  three  days. 

Just  why  diagnosing  a  perityphlitic  abscess 
should  have  cleared  the  diagnostic  atmosphere  to 


64  APPENDICITIS. 

such  an  extent  as  to  justify  one  in  declaring  that, 
since  the  discovery  of  the  abscess  there  could  be 
no  doubt  of  diffuse  peritonitis,  is  hard  to  under- 
stand. According  to  my  training  in  the  worth  of 
differential  diagnosis,  I  should  look  upon  such  a 
diagnosis  as  most  excellent  proof  that  the  peri- 
toneum was  still  intact,  and,  if  the  case  were 
handled  carefully,  its  intestine  sacredness  would 
remain  free  from  the  vandalizing  influence  of  toxic 
infection. 

I  am  not  inclined  to  accept  the  diagnosis,  for 
within  twenty-four  hours  the  abscess  broke  into 
the  cecum,  and  if  the  case  had  advanced  to  peri- 
typhlitic  abscess,  the  pus  would  have  burrowed 
downward  towards  the  groin  and  would  not  have 
terminated  as  early  as  it  did.  My  reason  for  so 
believing  is  that  we  always  have  a  typhlitic  or  ap- 
pendicular abscess  at  first,  which  naturally  opens 
into  the  bowel,  but  if  the  abscess  be  interfered 
with — handled  roughly  enough  to  rupture  the 
pyogenic  membrane — the  pus  is  forced  into  the 
subperitoneal  tissue  where  it  may  gather  and  be- 
come encysted,  but  this  is  exceedingly  doubtful. 
When  the  pyogenic  cyst  is  once  broken  the  pus  be- 
comes diffused,  and  as  it  has  no  retaining  mem- 
brane it  burrows  in  all  directions,  and  more  or  less 
of  it  is  absorbed,  causing  pyemia. 

The  parts  may  be  handled  to  such  an  extent 
that  the  abscess  will  be  forced  to  develop  low 


BIMANUAL  EXAMINATIONS.  65 

down  toward  the  groin,  so  low  that  the  natural 
outlet,  through  the  intestine,  will  be  impractic- 
able; under  such  circumstances  an  outside  open- 
ing with  drainage  is  the  only  choice  in  the  matter 
of  treatment. 

That  the  reader  may  understand  that  I  have  a 
very  good  foundation  for  my  strenuous  objections 
to  the  usual  bimanual  examinations  practiced  up- 
on all  appendicitis  cases,  I  shall  quote  a  descrip- 
tion of  what  one  of  America's  recognized  diag- 
nosticians, Dr.  G.  M.  Edebohls,  considers  a  cor- 
rect examination  and  he  declares  that  anything 
short  of  such  an  examination  is  useless  and  un- 
trustworthy : 

"The  examiner,  standing  at  the  patient's 
right,  begins  the  search  for  the  appendix  by  ap- 
plying two,  three,  or  four  fingers  of  his  right  hand, 
palmar  surface  downward,  almost  flat  upon  the 
abdomen,  at  or  near  the  umbilicus.  While  now  he 
draws  the  examining  fingers  over  the  abdomen  in 
a  straight  line  from  the  umbilicus  to  the  anterior 
superior  spine  of  the  right  ilium,  he  notices  suc- 
cessively the  character  of  the  various  structures 
as  they  come  beneath  and  escape  from  the  fingers 
passing  over  them.  In  doing  this  the  pressure  ex- 
erted must  be  deep  enough  to  recognize  distinct- 
ly, along  the  whole  route  traversed  by  the  examin- 
ing fingers,  the  resistant  surfaces  of  the  posterior 
abdominal  wall  and  of  the  pelvic  brim.    Only  in 


66  APPENDICITIS. 

this  way  can  we  positively  feel  the  normal  or  the 
slightly  enlarged  appendix ;  pressure  short  of  this 
must  necessarily  fail. 

"Palpation  with  pressure  short  of  reaching 
the  posterior  wall  fails  to  give  us  any  information 
of  value;  the  soft  and  yielding  structures  simply 
glide  away  from  the  approaching  finger.  When, 
however,  these  same  structures  are  compressed 
between  the  posterior  abdominal  wall,  and  the  ex- 
amining fingers,  they  are  recognized  with  a  fair 
degree  of  distinctness.  Pressure  deep  enough  to 
recognize  distinctly  the  posterior  abdominal  tvall, 
the  pelvic  brim,  and  the  structures  lying  be- 
tiveen  them  and  the  examining  finger  forms  the 
whole  secret  of  success  in  the  practice  of  palpation 
of  the  vermiform  appendix." 

Can  there  be  any  wonder  that  this  disease  is 
so  fulminating  in  the  hands  of  the  average  medical 
man  or  can  there  be  any  surprise  at  the  death 
rate  1  If  such  an  examination  were  given  to  a  well 
man  and  repeated  as  frequently  as  in  the  average 
appendicitis  case,  I  say  that  the  well  man  would 
soon  suffer  from  some  severe  disease  induced  by 
bruising. 

When  appendicitis  or  typhlitis  ends  in  an 
abscess,  and  the  pus  sac  is  ruptured  by  meddle- 
some, unskilled  treatment,  scientific  or  otherwise, 
causing  the  pus  to  burrow  toward  the  groin,  sur- 
gery is  the  only  treatment ;  there  is  no  hope  of  re- 


UNNECESSARY   EXAMINATIONS.  67 

covery  in  such  a  case  without  establishing 
thorough  drainage,  and  this  means  skilled  surgical 
treatment.  It  will  positively  be  a  miracle  if  such 
a  patient  recovers  without  an  operation.  I  have 
seen  these  cases  linger  for  two,  three,  and  even 
five  years.  The  type  of  cases  that  lingers  so  long 
is  one  that  has  an  imperfect  drainage,  either  into 
the  bowels  or  through  a  fistulous  outside  opening. 

What  per  cent,  of  cases  is  of  this  type?  That 
is  hard  to  tell  for  the  world  is  full  of  unskilled, 
heavy-handed  manipulators. 

I  have  seen  quite  a  number  of  this  type  who 
had  been  brought  into  this  unnecessary  state  by 
bungling  doctors  who  were  treating  them  for 
typhoid  fever  and  its  complications. 

I  say  without  fear  of  successful  contradiction 
that  there  never  was  and  never  will  be  such  a  case 
unless  it  is  made  so  by  the  worst  sort  of  malprac- 
tice. 

The  fact  that  a  diagnosis  was  made  in  spite  of 
the  tympanitic  distention  is  proof  that  a  dangerous 
force  was  used  in  doing  so,  converting  a  typhlitic 
abscess  into  a  perityphlitic  one,  and  doubt- 
lessly causing  premature  rupture  into  the  bowel. 
Any  professional  man,  with  the  right  regard  for 
his  patient 's  welfare,  and  the  judicial  understand- 
ing that  qualifies  him  for  taking  the  responsibility 
of  directing  the  treatment  of  so  important  a  case, 
would  scarcely  have  laid  the  weight  of  his  finger 


68  APPENDICITIS. 

on  an  abdomen  in  such  a  dangerous  condition. 
The  symptoms  and  course  of  the  malady  up  to 
that  time  should  have  told  the  real  diagnostician 
that  there  was  an  abscess  and  that  the  abscess 
would  rupture  into  the  cecum  if  it  were  not  med- 
dled with. 

No  one  with  a  proper  understanding  of  his  re- 
sponsibility in  such  a  case  would  have  thought  of 
undertaking  an  operation  with  a  patient  in  the 
physical  condition  that  this  man  was  reported  to 
be  in.  ' '  The  long  continuance  of  the  severe  symp- 
toms" is  proof  positive  that  the  "severe  symp- 
toms' '  were  false  or  man-made.] 

"Morphine  was  ordered  subcutaneously, 
Priessnitz  compresses  to  the  abdomen,  pellets  of 
ice  and  meat  jelly  by  mouth;  eventually  gastric 
lavage. ' '  [Under  the  circumstances  this  was  posi- 
tively murderous.  Acknowledging  to  such  treat- 
ment forces  me  to  declare  that  the  witness  is  in- 
competent, on  the  ground  that  no  one  has  a  right 
to  incriminate  himself.  Nothing  but  the  most  pos- 
itive malpractice  could  have  brought  a  case  of  this 
kind  to  need  gastric  lavage,  at  this  age  and  stage 
of  the  disease.] 

"Upon  the  sixth  day  of  the  disease  the  pic- 
ture changed."  [It  is  impossible  for  any  case  to 
arrive  at  this  state  of  maturation  in  six  days,  if 
allowed  to  take  its  own  course.]  "The  complexion 
became  sallow,  the  face  elongated,  the  eyes  hoi- 


ARTIFICIAL   SYMPTOMS.  69 

low;  the  pulse  was  140,  small,  but  quite  regular; 
the  temperature  was  101.3°  P.;"  [The  great  dis- 
crepancy between  the  pulse  and  temperature  was 
caused  by  the  opium.]  "  there  was  clammy  per- 
spiration and  a  cool  skin,  the  hands  were  cold; 
frequently  slight  eructations  occurred  and,  now 
and  then,  ineffectual  or  mild  paroxysms  of  vomit- 
ing of  a  greenish  yellow  material  with  a  slight 
fecal  odor. ' '  [All  these  symptoms  were  positively 
unnecessary.  They  were  built  by  food  and  drugs.] 
"The  mind  was  clear;  there  was  little  pain." 
[There  was  no  reason  why  the  mind  should  not 
be  clear,  and  there  should  have  been  no  pain  after 
the  third  day.]  "The  abdomen  became  somewhat 
softer,  much  less  painful,  and  was  readily  pal- 
pated and  percussed;  there  was  a  distinct  resist- 
ance about  the  size  of  a  hand,  quite  firm,  and  not 
fluctuating,  and  accompanied  by  marked  dullness, 
around  McBurney's  point  and  downward,  and 
only  in  this  region  severe  stabbing  pain;  in  other 
areas  no  dullness."  [The  sallow  complexion, 
elongated  face,  hollow  eyes,  pulse  140,  tempera- 
ture 101.3°  F.,  clammy  skin,  cold  extremities,  green- 
ish vomiting  with  fecal  odor ;  all  these  symptoms 
would  have  been  ominous  of  a  fatal  collapse  had  it 
not  been  that  the  symptoms  were  those  of  narcot- 
ism, and  not  the  symptoms  of  peritonitis  as  they 
were  supposed  to  be.  The  small,  regular  and  fre- 
quent pulse,  the  clammy  perspiration,    cool  skin, 


70  APPENDICITIS. 

cold  hands,  the  eructations  and  mild  paroxysms 
of  vomiting  of  greenish  yellow  material  with  fecal 
odor,  were  symptoms  produced  by  opium,  food 
and  morphine,  as  should  have  been  fully  apparent 
to  any  medical  mind. 

If  the  patient  had  been  treated  rationally 
from  the  start,  at  this  stage  of  the  disease  he 
would  have  been  as  comfortable  as  at  any  time  in 
his  life,  and  after  the  opening  of  the  abscess, 
forced  though  it  was  and  followed  by  those  symp- 
toms, the  patient  still  had  a  chance  to  get  well  if 
he  had  been  left  alone.  See  how  he  responded 
when  given  a  little  opportunity.  Only  twenty- 
four  hours  after  "the  intake  of  food  was  reduced 
to  almost  nothing"  the  abdomen  was  softer  and 
readily  palpated  and  percussed.  Just  imagine, 
reader,  what  a  difference  there  would  have  been 
in  this  case  if  the  poor,  miserable  victim  had  been 
allowed  the  quiet  he  so  much  needed — if  he  had 
been  left  without  daily  bimanual  examinations, 
food  and  drugs.  The  patient  was  kept  in  an  ab- 
normal state  from  the  first  hour  that  the  doctoring 
began  to  the  last  hour  of  his  life.] 

"The  symptoms  were  those  of  moderately 
severe  peritoneal  collapse;"  [In  all  the  cases  I 
have  ever  seen,  I  never  knew  of  one  showing  any 
symptoms  of  collapse  when  the  abscess  ruptured.] 
"the  prognosis  was  very  grave  although  not  posi- 
tively hopeless. '.'    [If  the  symptoms  had  not  been 


DRUG  COLLAPSE.  71 

those  of  drug  and  food  poisoning  they  were  very 
grave.]  "Treatment:  Small  quantities  of  alcohol, 
to  be  followed  by  camphor."  [All  the  treatment 
necessary  was  absolute  quiet — no  drugs,  no  food — 
nothing  until  nature  had  time  to  react  fully ;  then 
there  would  have  been  a  full  and  speedy  recov- 
ery. Alcohol  and  camphor  were  injurious  to  a 
body  already  suffering  from  opium  paralysis,  for 
all  such  drugs  are  heart  depressants. 

As  I  have  said  for  years :  The  physician  who 
gives  drugs  can't  possibly  know  where  his  patient 
is.  "Peritoneal  collapse!"  If  there  had  been  no 
narcotism  there  would  have  been  no  appearance 
of  collapse.  Every  symptom  giving  the  appear- 
ance of  collapse  was  due  to  opium  and  morphine. 
I  have  seen  such  collapses  for  I  have  made  them, 
and  I  have  suffered  all  the  torments  possible  in 
this  world  of  medical  uncertainty.  For  fifteen 
years  after  starting  to  practice  my  profession  I 
labored  hard  with  symptoms  of  my  own  making. 
After  drug  action  and  symptoms  were  once  de- 
veloped, I  knew  nothing  more  about  my  patients ; 
it  is  true  I  guessed,  and  theorized,  and  reasoned, 
but  in  truth  I  did  not  know  positively  just  where 
my  patients  were.  I  consoled  myself  in  those  days 
with  the  thought  that  some  day  I  should  know ;  I 
believed  that  the  fault  was  with  me,  that  I  was 
lacking  in  diagnostic  ability,  and  that  by  hard 
work  the  time  would  come  when  I  could  read  dis- 


72  APPENDICITIS. 

ease  by  its  symptoms  as  well  as  the  best,  for  I 
then  thought  the  big  men  of  the  profession  knew 
everything  they  pretended  to  know.  This  was  my 
ambition,  but  the  ability  to  size  up  symptoms  un- 
der given  conditions  and  tell  their  true  worth  for- 
ever eluded  me  and  kept  me  in  a  state  of  unrest 
and  discontent  that  was  next  to  ruining  my  life. 
If  light  had  not  come  when  it  did  I  should  have 
abandoned  the  profession,  but  it  came  accidental- 
ly ;  it  could  not  come  otherwise  for  I  did  not  know 
how  to  look  for  it.  In  the  course  of  time  I  stored 
in  my  memory  many  cases  that  from  accident  or 
caprice  had  recovered  without  drugs  and  food. 
The  satisfactory  advance  made  by  sick  people,  suf- 
fering from  different  diseases,  when  they  were 
left  without  food  or  drugs,  occurred  so  often,  and 
with  such  unvarying  regularity  that  it  ceased  to 
be  a  coincident — it  was  absurd  for  me  to  continue 
to  explain  the  results  by  the  hackneyed  word  ' '  co- 
incident,' '  a  word  that  is  usually  loaded  with  a 
lot  of  dogmatism,  idleness  and  selfishness. 

When  I  accepted  the  changes,  taking  place 
without  medical  aid,  interruption  and  interfer- 
ence, as  true  cures,  and  so  much  a  part  of  nature, 
and  so  intimately  blended  with  the  fixed  laws  of 
nature  that  like  results  could  be  looked  for  with 
the  same  degree  of  certainty  that  we  look  for  the 
rising  or  setting  of  the  sun,  I  busied  myself  in 
formulating  a  plan  of  cure  as  nearly  in  accordance 


NATURE  CURES.  73 

with  natural  laws  as  I  could.  I  am  now,  and  have 
been  for  twenty  years,  developing  in  this  line,  and 
I  have  gone  far  enough  to  declare  that  I  have 
watched  symptoms  start,  mature,  and  decline,  and 
in  this  way  have  learned,  by  contrasting  the  symp- 
toms in  a  given  case  that  has  not  been  medicated, 
with  those  of  a  similar  case  that  has  been  medi- 
cated, to  know  the  full  value  of  symptoms  under 
medication,  as  well  as  the  full  value  of  the  symp- 
toms when  not  under  medication.  This  knowledge 
I  am  using  in  analyzing  this  medical  classic  and 
from  my  standpoint  I  can  see  how  very  easy  it 
was  for  the  author  of  the  article  under  considera- 
tion to  blunder  along  as  he  did.  The  doctor  should 
not  feel  lonesome,  however,  for  he  has  a  world  of 
company.] 

"This  condition  lasted  nearly  twenty-four 
hours ;  then  a  very  large  and  hard  stool,  followed 
by  a  thin  one  of  hemorrhagico-purulent  character 
was  discharged  and  simultaneously  a  decided 
change  took  place.  The  appearance  and  pulse  im- 
proved; the  abdomen  became  softer  with  the  ex- 
ception of  the  marked  resistance  upon  the  right 
side  low  down,  and  the  fever  slightly  remittent,  its 
maximum  101°  F.  Vomiting  did  not  recur ;  the  pa- 
tient moved  about  somewhat  in  bed  and  slept  sev- 
eral hours  in  a  half -lateral  posture.  Meat  jelly  and 
cold  beef  tea  were  swallowed.' '  [This  feeding  was 
the  beginning  of  mistakes  for  the  second  round. 


74  APPENDICITIS. 

If  this  patient  had  been  left  distressingly  alone 
until  he  could  have  thrown  off  his  opium  poison 
and  become  normal,  and  allowed  the  abscess  to 
drain  and  close,  all  would  have  been  well.  This, 
I  assume,  would  have  been  the  ending  if  the  vigor- 
ous examination  that  was  given  the  patient  the 
day  before  the  collapse  had  not  prematurely  rup- 
tured the  abscess  both  into  the  gut  and  into  the 
subperitoneal  region  converting  an  appendicular 
abscess  into  a  perityphlitic  one.] 

"Upon  the  next  day  there  were  several  hem- 
orrhagico-purulent  stools,  the  urine  was  profuse 
and  voided  without  pain.  Nevertheless,  firm,  flat 
resistance  was  still  felt  in  the  lower  right  side 
and  upon  pressure  there  was  lancinating  pain ;  no 
fever."  [What  was  the  need  of  this  everlasting, 
eternal,  never-ending  manipulating  to  find  how 
much  induration  there  was!  Nothing  but  harm 
could  come  from  such  senseless  officiousness.  The 
punching,  feeling  and  manipulating  of  patients 
without  a  reasonable  excuse  is  a  very  bad  habit, 
one  that  is  peculiar  to  young  and  inexperienced 
men.  There  is  no  reason,  no  object,  no  purpose 
in  it;  it  is  just  a  bad  habit.] 

"There  could  be  no  doubt  that  the  perityph- 
litic abscess  had  ruptured  into  the  intestine,  and 
that  in  consequence  of  this  the  diffuse  peritonitis 
had  at  once  been  relieved."  [There  was  no  peri- 
tonitis up  to  this  time,  except  the  small  portion 


MEDICAL  SOPHISTRY.  75 

that  represented  the  peritoneal  covering  of  the 
organ  or  organs  involved  in  the  primary  infection. 
The  peritoneal  cavity,  or  the  peritoneum  as  an 
organ,  was  not  involved  in  this  disease;  hence  it 
is  an  error  to  say  that  there  was  diffuse  periton- 
itis which  was  at  once  relieved  by  the  rupturing 
of  the  abscess  into  the  intestine.  It  is  worth  some- 
thing to  know  the  difference  between  a  drug-cre- 
ated phantom  peritonitis  and  a  true  peritonitis. 
It  is  not  for  the  sake  of  controversy  that  I  am 
taking  exceptions  to  the  opinions  advanced  in  this 
case,  neither  is  it  because  I  delight  in  criticising, 
differing  from  or  finding  fault  with  authority;  I 
have  a  more  laudable  reason — one  that  I  consider 
humane  and  justifiable — namely,  to  point  out  to 
the  few  who  happen  to  read  this  book,  a  safe  and 
life-preserving  plan  of  treating  one  of  the  most 
talked  about,  and  (because  of  bad — decidedly  bad 
— treatment)  one  of  the  most  fatal  maladies  of  this 
age.  To-do  this  it  is  necessary  to  point  out  and 
teach  these  few  how  to  reason  on  the  subject,  and 
how  to  weigh  with  something  like  exactness  the 
various  important  symptoms  that  present  them- 
selves under  varying  styles  of  treatment. 

If  a  young  physician  is  guided  in  his  opinions 
by  authority — if  he  believes  that  the  last  word  has 
been  said,  because  he  has  the  last  book  from  the 
leading  authority,  and  if  said  authority  has  not 
yet  learned  that  there  is  a  true  and  a  phantom  dif- 


76  APPENDICITIS. 

fuse  peritonitis,  said  young  man  is  not  in  line  for 
saving  life;  on  the  contrary,  lie  is  liable  to  mis- 
manage and  meet  with  as  great  a  failure,  and  be 
the  cause  of  as  unnecessary  a  death  as  was  the 
good  doctor  from  whom  we  are  quoting  and  of 
whose  medical  sophistry  I  am  trying  to  give  the 
true  qualitative  and  quantitative  analysis. 

Rupture  into  the  gut  is  exactly  what  will  hap- 
pen every  time,  in  all  cases,  if  left  alone  and  no 
food  nor  drugs  given.] 

"Treatment:  Warm,  followed  by  hot,  flax- 
seed poultices ;  rest,  freshly  expressed  meat  juice 
or  beef  tea,  in  all  200  grams ;  thin  gruel  made  with 
milk,  200  grams;  wine,  100  grams  in  twenty-four 
hours,  small  portions  to  be  taken  every  two  hours ; 
no  drugs. ' '  [A  little  over  six  ounces  of  meat  juice 
and  six  ounces  of  gruel  made  with  milk!  The 
starch  contained  in  the  gruel  will  always  create 
gas  in  these  cases  and  stimulate  peristalsis;  the 
gas  inflates  the  cecum  and  drives  the  contents  of 
the  bowels  into  the  abscess  cavity;  this  sets  up 
secondary  inflammation.  The  meat  juice  and  wine 
could  have  been  left  out  to  the  patient's  better- 
ment. It  is  refreshing  to  know  that  no  drugs  were 
given,  and  if  the  case  had  been  treated  from  the 
start  on  the  no-drug  plan  the  course  and  ending 
would  have  been  very  different.  The  poultices 
would  have  done  as  much  good  if  they  had  been 
put  on  the  leg  of  his  bed,  and  much  less  harm.] 


METEORISM.  77 

"This  improvement  continued  for  several 
days  and  even  became  more  marked.  The  ab- 
domen returned  to  the  norm  with  the  exception 
of  the  ileo-cecal  region;  there  was  a  small  stool 
daily  without  recognizable  pus ;  no  fever. 

"Upon  the  twelfth  day  of  the  disease  vomit- 
ing suddenly  recurred,  with  severe,  diffuse  ab- 
dominal pain,  marked  meteorism,  and  fever  to 
about  102.2°  P.;"  [True,  diffuse  peritonitis  set 
in  at  this  time.]  "the  symptoms  increased  in 
severity,  and  changed  during  the  collapse,  his  tem- 
perature 97.3°  F.,  pulse  160,  thready,  uneven;  con- 
spicuous facies  hippocratica ;  no  pain;  a  slight 
comatose  condition,  moderate  meteorism,  no  move- 
ment of  the  bowels.  Stimulants  were  without  ef- 
fect ;  subcutaneous  saline  infusion  revived  the  pa- 
tient but  only  for  a  short  time,  and  death  occurred 
the  following  morning  upon  the  fourteenth  day  of 
the  disease. "  [Meteorism!  What  is  it?  A 
blown-up  condition  of  the  bowels.  Gruel  caused 
gas  to  form,  the  gas  was  driven  into  the  abscess 
cavity,  reinfection  took  place,  which  ended  in  dif- 
fuse peritonitis.  The  patient's  resistance  was 
used  up  and,  being  exhausted,  he  died.  He  had 
made  a  brave  fight  against  all  sorts  of  odds  but 
the  second  round  was  too  much  for  him.] 

"Autopsy:  Normal  condition  of  the  serosa 
above  the  omentum;  the  appendix  surrounded  by 
adhesions  embedded  in  fecal  pus,  gangrenous  to- 
ward its  terminal  portion,  and  showing  perfora- 


78  APPENDICITIS. 

tion ;  fecal  calculus  in  the  pus ;  appendix  movable 
toward  the  cecum."  [Just  what  may  be  ex- 
pected in  all  cases!  Nature  is  always  busy  rein- 
forcing weak  points,  but  the  modern  physician 
and  surgeon  is  too  wily  and  artful  for  her;  she 
can't  always  anticipate  his  moves,  hence  she  can't 
always  fortify  successfully.]  "Agglutinated  point 
of  rupture  at  the  median  periphery  of  the  cecum 
near  the  ileo-cecal  valve.  The  perityphlitic  pus 
appeared  to  be  sacculated  by  adherent  intestinal 
coils,  but  beyond  the  adhesions  in  the  free  ab- 
dominal cavity  below  the  omentum  there  was  dif- 
fuse, fresh,  fibrinous  peritonitis  and  distributed 
here  and  there  small  quantities  of  thin,  putrid  pus 
(many  bacteria,  large  quantities  of  streptococci 
and  coli  bacilli).  The  peritoneum  was  injected, 
of  a  delicate  rose-red  color,  here  and  there  covered 
with  fine,  mucus-like  pseudo-membranes.  Heart 
flabby. ' '  [The  autopsy  showed  nothing  more  than 
would  be  expected.  The  fresh  peritonitis  confirms 
what  I  say  that  a  reinfection  was  forced  because 
of  the  character  of  the  food.  The  meteorism  op- 
posed relaxation  and  rest,  two  conditions  posi- 
tively necessary  and  without  Which  healing  can  not 
take  place.  What  was  to  hinder  the  heart  from 
being  flabby?  Drugs  and  systemic  infection  are 
quite  enough. 

In  proper  hands  this  young  man  would  not 
have  been  very  sick;  possibly  his  trouble  would 


INTESTINAL  PUTREFACTION.  79 

have  been  thrown  off  and  the  inflammation  passed 
off  by  resolution. 

The  following  should  be  of  interest  for  it  is  a 
very  scientific  explanation  of  how  the  young  man 
came  to  die:] 

"The  clinical  history  is  in  every  respect  typ- 
ical and  instructive. 

"It  shows  us  that  the  origin  of  peritonitis 
which  is  by  far  the  most  common,  is  in  a  diseased 
appendix.  At  the  autopsy  this  was  found  necrotic 
and  perforated.  It  is  questionable  whether  the 
perforation  existed  from  the  onset  of  the  disease ; 
it  is  possible  that  at  first  an  ulcer  extending  to 
the  serosa  caused  an  infection  of  the  peritoneum; 
at  all  events  this  occurred  acutely,  and  produced 
the  sharply  defined  disease. ' '  [I  agree.  The  per- 
foration brought  on  the  relapse  and  the  collapse.] 
"The  clinical  abdominal  symptoms  in  the  first 
period  of  the  malady  pointed  to  the  fact  that  at 
the  onset  there  had  been  a  diffuse  inflammation 
of  the  peritoneum,  and  that  later,  by  the  adhesions 
to  the  appendix  which  were  found  at  the  autopsy 
an  early  encapsulation  of  pus  had  taken  place  in 
the  ileo-cecal  region;  this  produced  a  purulent 
softening  in  the  wall  of  the  cecum  and  led  to  the 
favorable  rupture  of  pus  into  the  intestine  and 
to  an  immediate  amelioration  of  the  acute  peri- 
tonitis. The  point  of  rupture,  however,  then 
closed,  and  partly  perhaps  to  the  action  of  fresh 
infectious  and  toxic  material,  perhaps  only  to  the 


80  APPENDICITIS. 

perforation  of  the  appendix,  may  be  ascribed  the 
exacerbation  of  the  peritonitis,  that  is,  a  renewed 
attack  which  caused  the  death  of  the  patient. ' ' 

[The  symptoms  were  those  of  intestinal  pu- 
trefaction with  local  inflammation  of  the  cecum 
and,  as  the  history  of  the  case  has  pointed  out, 
was  located  in  that  part  of  the  cecum  giving  at- 
tachment to  the  appendix,  for  the  autopsy  showed 
that  the  appendix  was  surrounded  by  adhesions 
and  imbedded  in  fecal  pus.  Please  note  particu- 
larly :  The  appendix  was  found  in  a  pus  cavity — 
a  perityphlitic  abscess.  Why  shouldn't  the  ap- 
pendix be  necrosed?  Located  in  a  field  of  inflam- 
mation, blown  up,  distended  beyond  its  vital  in- 
tegrity; why  should  it  not  become  gangrenous! 
It  doesn't  matter  when  the  perforation  of  the  ap- 
pendix took  place  for  it  is  quite  evident  that  there 
was  not  enough  disease  of  the  appendix  to  cause 
its  perforation  until  after  it  had  become  incased 
in  the  abscess  cavity,  and  if  the  young  man  could 
have  been  freed  from  the  treatment  he  received 
and  could  have  been  given  the  necessary  rest  the 
abscess  cavity  would  have  emptied  itself ,  necrosed 
appendix  and  all,  into  the  bowel  and  he  would 
have  made  a  perfect  recovery. 

"The  point  of  rupture  closed!"  How  could  a 
rupture  into  a  distended  gut  close  ?  The  distention 
was  greater  after  the  rupture  than  before.  Fresh 
infection  could  not  take  place  without  a  power  to 
force  the  putrefaction  greater  than  the  force  that 


OPIUM    PARALYSIS.  81 

existed  before  the  abscess  broke  into  the  cecum. 
Let  us  reason  together :  Nature  fought  success- 
fully against  heavy  odds  before  the  rupture. 
There  was  gas  distention  of  bowels  interfering 
by  pressure  with  the  circulation  and  increasing 
the  area  of  destruction  of  tissue;  frequent  retch- 
ing and  vomiting  interfering  by  stretching  and 
probably  tearing,  threatening  disruption  to  the 
plastic  process  that  was  going  on  to  close  in  the 
disorganizing  and  necrosing  processes;  the  fre- 
quent examinations,  and  manipulations  for  diag- 
nostic purposes,  etc.,  but,  in  spite  of  all  this  op- 
position, fatal  infection  was  successfully  resisted ; 
then,  after  the  rupture  and  discharge,  the  relaxa- 
tion, the  calling  of f  by  nature  of  all  her  defenses, 
showed  that  the  battle  was  won.  All  the  defense 
yet  left  was  the  hard  induration,  "firm,  flat  re- 
sistance.' >  This  induration  was  quite  sufficient  to 
prevent  reinfection,  had  there  not  been  something 
out  of  the  regular  order  to  interfere.  In  this  case 
there  was  a  prostrated  muscular  system.  The 
narcotic  had  left  the  patient  without  muscular 
power.  The  starchy  food  created  gas,  and  the 
bowels,  not  having  their  natural  tone,  gave  way 
to  the  gas  until  there  was  "Meteorism,"  not 
tympanites  but  meteorism  which  means  to  blow 
up  or  distend  all  that  is  possible. 

Such  a  state  as  that  means  mechanical  inter- 
ference with  every  organ  in  the  thoracic,  abdomi- 
nal and  pelvic  cavities,  and,  besides  the  pressure 


82  APPENDICITIS. 

and  interference  in  drainage  and  the  blowing  into 
the  abscess  cavity  and  into  the  pyogenic  mem- 
brane gas  loaded  with  infection,  there  was  an 
almost  fatal  interference  with  the  action  of  the 
heart  and  lungs. 

The  prostrating  effect  on  the  muscular  system 
of  the  septic  or  putrefactive  poison  was  nothing 
to  be  compared  to  the  paralyzing  effect  of  opium. 
I  believe  this  man  would  have  survived  every  in- 
terference if  the  milk  gruel  had  been  left  out,  but 
acting  as  it  did,  it  proved  to  be  the  last  straw.] 

"In  regard  to  the  fulminant  symptoms  at  the 
onset  of  the  disease,  however,  it  is  more  likely  that 
even  then  perforation  had  already  occurred,  and 
that  the  final  and  fatal  exacerbation  was  in  conse- 
quence of  adhesions  formed  in  the  first  period 
which  were  powerless  to  resist  the  entrance  of 
organisms  producing  inflammation.  The  pus 
finally  broke  through  the  adhesions,  and  produced 
diffuse  peritonitis. '  ■ 

[It  is  a  technical  point  unnecessary  to  raise 
whether  the  adhesions  formed  in  the  first  or  the 
last  period;  they  were  formed  without  question; 
and  if  they  were  formed  in  the  beginning,  as 
doubtless  they  were,  they  withstood  the  most 
severe  and  trying  period  of  their  existence,  which 
was  before  the  abscess  broke  into  the  bowels,  and 
so  far  as  being  able  to  resist  to  the  very  last,  there 
has  been  no  evidence  to  prove  that  the  last  infec- 
tion was  because  of  any  lack  of  power  of  resist- 


FULMINANT  DISEASES.  83 

ance  on  their  part  for  the  autopsy  showed  them 
intact.  It  is  doubtful  if  anything  but  sound  tissue 
could  have  withstood  the  strain  that  was  put  upon 
this  man's  diseased  cecum  from  gas  distention. 
The  infection-laden  gas  could  find  a  way  anywhere 
in  diseased  tissue  and  broken  continuity.  Why 
should  the  pus  break  through  the  adhesions  and 
find  its  way  into  the  peritoneum  after  they  had 
been  able  to  make  an  effectual  resistance  till  the 
bulk  of  it  had  forced  a  passage  into  the  bowel? 
Why  should  the  adhesions  have  less  power  to  re- 
sist when  there  is  less  strain  upon  them  and  also 
a  patent  outlet  for  the  pus?  I  fear  our  German 
friend  of  "Die  Deutsche  Klinik"  had  " booze "  in 
his  logic  when  he  was  explaining  how  his  patient 
came  to  die.] 

"  Moreover,  the  bacterial  finding  of  strepto- 
cocci and  coli  bacilli  in  the  perityphlitic  abscess 
is  typical,  and  the  limitation  of  the  diffuse  peri- 
tonitis to  areas  below  the  omentum  is  also  in- 
structive. This  simultaneously  prevented  the  in- 
vasion of  organisms  producing  inflammation  into 
the  serous  surfaces  above.' ' 

[There  is  nothing  strange  about  this  for  na- 
ture works  for  the  purpose  of  preventing  "serous 
surface' '  invasion,  and  it  takes  a  deal  of  malprac- 
tice to  force  such  an  infection.  If  nature's  pro- 
visions against  peritoneal  inflammation  were  not 
as  great  as  they  are,  few  people  with  intestinal 
putrefactive  diseases,  from  cholera  infantum  in 


84  APPENDICITIS. 

babyhood  to  proctitis  in  old  age,  would  get  well, 
for  most  of  the  treatment  for  one  and  all  of  these 
diseases  is  obstructive  rather  than  conservative 
and  helpful.] 

"This  strong  man,  aged  31,  had  previously 
regarded  himself  as  perfectly  well.  Nothing  indi- 
cated the  danger  in  which  he  found  himself  and 
which  had  existed  since  the  appearance  of  the 
fecal  calculus,  the  time  when  this  had  formed 
being  impossible  to  determine.  The  disease  ap- 
peared acutely  with  fulminant  symptoms. ' ' 

[He  was,  indeed,  unfortunate,  but  his  greatest 
misfortune,  as  I  see  it,  was  his  treatment.  Every 
acute  disease  is  fulminant,  even  indigestion  is  ful- 
minant, but  the  force  of  the  warring  elements  is 
soon  expended  and  unless  reinforced  by  fresh  ele- 
ments the  fulmination  must  end. 

In  diseases  such  as  typhoid  fever,  appendi- 
citis and  typhlitis,  we  have  first  of  all  a  constitu- 
tional derangement  brought  on  by  errors  of  life. 
The  general  resistance  is  lowered  from  nerve- 
exhausting  habits;  the  general  tone  of  digestion 
is  below  par  and  the  bowel  contents  are  maintain- 
ing a  higher  toxic  state  than  usual ;  we  have  added 
to  this  condition  an  unusual  tax  in  a  long  run  of 
hot  weather,  business  worries  or  unusual  mental, 
physical  or  digestive  strain,  following  which  acute 
intestinal  indigestion  manifests  with  a  sudden  ex- 
plosion; or  there  takes  place  a  transformation  of 
the  contents  of  the  bowels  into  an  intense  putre- 


IMMUNITY.  85 

faction  which  infects  a  portion  of  the  mucosa  that 
has  been  rendered  susceptible  by  pressure  from 
fecal  impaction,  concretions,  or  any  cause  capable 
of  devitalizing.  If  the  infection  takes  place  in 
Peyer's  patches,  typhoid  fever  is  the  consequence ; 
if  the  local  trouble  is  of  the  cecum,  typhlitis  will 
result,  and  if  the  local  devitalization  is  in  the  ap- 
pendix, brought  on  from  the  irritating  effects  of 
a  fecal  calculus,  appendicitis  will  result. 

These  diseases  may  start  in  a  fulminant  man- 
ner as  suggested — with  an  acute  intestinal  indi- 
gestion, which  will  die  down  as  soon  as  all  the 
elements  that  combine  to  set  off  this  fulmination 
have  expended  their  force  and  unless  fresh  mate- 
rial be  added  everything  must  settle  down  to  a 
local  trouble.  Or  if  the  primary  irritation  is  sub- 
jected to  a  light  form  of  toxic  infection  the  devel- 
opment of  the  disease  will  be  much  more  insidious 
and  will  require  much  more  time  to  come  to  its 
maturity,  or  its  fulminating  stage. 

The  reason  for  this  is  that  each  person  has  a 
■  cultivated  immunity  to  a  given  toxic  state  of  the 
intestinal  contents,  and  when  from  pressure  or  the 
irritation  caused  by  a  calculus,  there  is  a  denuda- 
tion of  the  mucosa  the  infection  that  takes  place 
has  not  the  power  to  arouse  a  systemic  resist- 
ance, but  can  cause  only  a  local  inflammation ;  this 
inflammation  may  end  in  ulceration,  or  it  may 
cause  a  thickening  of  the  parts  and  interfere  with 
drainage  from  mucous  or  glandular  pockets ;  then 


86  APPENDICITIS. 

the  locked  up  secretions  become  intensely  toxic, 
and  this  sets  up  a  new  infection  much  greater  than 
the  first  and  powerful  enough  to  cause  the  system 
to  call  out  its  militia  to  put  down  the  rebellion. 
Now  we  have  fulmination,  but  if  food  and  drugs 
are  withheld  it  ends  soon.] . 

i i  Severe  abdominal  pain  with  tense  abdominal 
walls,  fever  and  vomiting  form  the  characteristic 
triad  in  the  first  phase  of  the  disease ;  less  rapidly 
does  meteorism  appear.  This  depends  upon 
whether  the  inflammation  of  the  serosa  quickly 
spreads  or  remains  local.  Peritoneal  meteorism 
is  peculiar.  The  abdomen  is  uniformly  distended, 
balloon-like ;  the  muscles  as  well  as  the  rest  of  the 
abdominal  walls  are  tense.  It  must  be  added,  how- 
ever, that  in  spite  of  the  excruciating  pain  upon 
touch  there  is  no  sign  of  contraction  of  the  ab- 
dominal muscles,  of  the  "muscular  resistance7 ' 
(defense  musculaire)  which  is  so  common  on  pres- 
sure in  other  forms  of  abdominal  pain,  particu- 
larly when  circumscribed. ' '  [Distention  from  any 
cause — or  stretching  of  muscular  fiber — causes 
paralysis  for  the  time  being.]  ' '  The  same  is  true 
of  the  diaphragm;  it  is  forced  upward,  the  mus- 
cles are  therefore  elongated  and  tense;  but  there 
is  no  evidence  of  active  contractions.  Abdominal 
respiration  ceases ;  gradually  then,  as  may  be  rec- 
ognized by  the  limits  of  percussion,  increasing 
loss  of  muscle  tonus  is  added.    In  this  case  the 


ABDOMINAL  PAIN.  87 

autopsy  showed  that  the  peritonitis  had  not  ad- 
vanced up  to  the  serosa  of  the  diaphragm. ' ' 

[The  muscle  tonus  when  a  patient  is  under 
the  influence  of  opiates  cannot  be  reckoned  with, 
for  that  drug  paralyzes  the  muscles,  and  the 
bowels  fill  with  gas  as  was  seen  in  this  case  up 
to  the  day  before  the  abscess  ruptured;  on  that 
day  feeding  had  been  suspended,  resulting  in  a 
decrease  of  gas  and  an  amelioration  of  all  the 
symptoms.] 

"  Among  these  signs  pain,  either  spontaneous 
or  upon  touch,  a  rise  in  temperature,  increased 
frequency  of  the  pulse  and,  in  general,  the  signs 
of  severe  illness,  are  to  be  looked  upon  as  the  local 
and  general  symptoms  of  a  severe  septic  inflam- 
mation; vomiting,  at  least  in  the  first  stages  of 
peritonitis,  was  due  to  decided  reflex  irritation  of 
the  numerous  branches  of  the  peritoneal  nerves; 
the  fecal  discharges  at  the  onset  may  be  explained, 
but  by  no  means  invariably,  as  due  to  peristalsis 
acting  reflexly.  The  constipation  which  followed 
this,  however,  as  well  as  the  meteorism,  must  be 
attributed  to  a  hypotonia  and  paralysis  of  the 
musculature  of  the  intestine  by  collateral  edema. ' ' 

[Beautiful  sophistry.  Words  well  woven  to- 
gether are  captivating  and  frequently  dethrone 
reason.  If  I  didn  't  happen  to  know  better  I  might 
really  believe  the  author  of  this  contribution  to 
medical  science  knew  exactly  what  he  was  talking 
about. 


88  APPENDICITIS. 

The  constipation  in  such  diseases  as  this  is 
caused  by  the  fixing,  or  natural  resistance  to  mo- 
tion, which  is  always  to  be  found  in  diseases  of 
the  bowels  and  is  one  of  nature's  conservative 
measures.  The  hypotonia  or  paralysis  of  the  mus- 
culature was  brought  about  by  the  opium;  and  it 
is  certainly  strange  that  educated  men  can  build 
a  symptom  or  condition  by  the  administration  of 
drugs  and  yet  remain  absolutely  unconscious  of 
the  part  they  are  playing,  and  proceed  to  build  a 
beautiful  theory  explanatory  of  results.] 

' '  The  excessive  abdominal  pain,  increased  by 
movement  and  on  the  slightest  pressure,  caused 
the  patient  to  remain  motionless  upon  his  back 
and  to  avoid  the  slightest  movement  of  the  abdo- 
men either  by  speaking  or  coughing."  [This  is 
a  characteristic  symptom  when  there  is  great  dis- 
tention of  the  bowels.] 

"At  the  start  the  temperature  was  uniformly 
high,  but  later  remissions  in  the  pus  fever  were 
recognized. ' '  [All  fever  would  have  disappeared 
had  it  not  been  that  the  intestinal  putrefaction 
was  kept  alive  by  feeding.]  "The  pulse  from  the 
onset  was  comparatively  frequent,  regular  and 
somewhat  tense. 

"The  vomitus  was  at  first  composed  of  the 
gastric  contents,  the  bile  of  a  peculiarly  pure, 
grass-green,  biliverdin  color  mixed  with  a  yellow- 
ish chyme-like  material,  and  in  the  later  stages  of 
the  disease  showed  thin  masses  having  a  fecal 


COMPLICATIONS.  89 

odor  (ileus  paralyticus).  In  regard  to  the  dejecta, 
the  two  passages  at  the  onset  of  the  disease 
pointed  to  increased  peristalsis ;  this  was  of  short 
duration,  soon  changing  to  the  opposite  condition, 
and  until  the  rupture  of  the  perityphlitic  abscess 
absolute  constipation  existed." 

[The  vomiting  would  have  gone  to  stay  within 
three  days  if  no  drugs  nor  food  had  been  given; 
as  it  was,  when  real  vomiting  ceased  the  opium 
nausea  began. 

This  patient  was  not  allowed  to  come  into 
that  state  of  peristaltic  elimination  that  is  due  in 
all  cases  in  three  days  at  the  farthest,  and  which 
would  have  come  to  this  man  if  food  and  drugs 
had  been  withheld.] 

"Pain  upon  urination  and  strangury  was  due 
to  inflammation  of  the  peritoneal  coat  of  the  blad- 
der, in  which  a  noticeable  irritation  was  produced 
by  slight  distention  as  well  as  by  contraction  of 
the  bladder.  The  albuminuria  was  the  well  known 
infectio-toxic  ' febrile'  form;  indicanuria  was  in 
proportion  to  the  fecal  stasis. 

"In  the  course  of  the  next  few  days  a  new 
symptom  was  added  to  this  group:  Exudation, 
which  was  demonstrable  both  by  palpation  and 
percussion.  It  was  the  natural  consequence  of 
inflammation  of  the  peritoneum,  and  was  both  of 
diagnostic  value  as  indicating  general  peritonitis 
and  of  special  value  in  that,  more  definitely  than 
the  pain,  it  pointed  to  the  original  seat  of  the 


90  APPENDICITIS. 

affection,  which,  according  to  present  indications, 
could  only  have  been  an  internal  incarceration 
following  right-sided  inguinal  hernia,  or  femoral 
hernia,  or  appendicitis.  As  neither  the  history 
nor  the  general  status  (normal  condition  of  the 
hernial  rings)  furnished  any  points  of  support  for 
the  first  view,  only  the  diagnosis  of  appendicitis, 
that  is,  of  perforation  of  the  appendix,  could  be 
made  with  that  degree  of  certainty  attainable  in 
diseases  of  the  abdominal  cavity  in  general. 

"  After  the  appearance  of  these  symptoms,  a 
more  or  less  firmly  adherent  but  limited  perity- 
phlitic  abscess,  and  a  less  intense  although  well 
developed  peritonitis  in  this  region,  were  as- 
sumed; the  latter,  notwithstanding  the  painful 
meteorism,  was  not  necessarily  diffuse  in  the  strict 
sense  of  the  term ;  the  omentum  often  protects  the 
upper  abdominal  cavity  from  infection,  as  was 
proven  in  this  case  at  the  autopsy.  It  is  possible 
that  this  diffuse  peritonitis,  which  did  not  in  the 
early  period  of  the  affection  extend  beyond  the 
limited  local  focus,  was  not  due  to  the  intestinal 
contents  and  to  bacteria,  but  chiefly  to  bacterial 
toxins  which  arose  from  the  circumscribed  orig- 
inal focus.  This  fact  is  pointed  out  by  the  prompt 
retrogression  of  the  diffuse  peritoneal  symptoms 
after  rupture  of  the  abscess ;  the  diffuse  periton- 
itis of  this  stage  might  then  be  designated  a  non- 
bacterial 'chemical'  inflammation,  according  to 
the  terminology  now  in  vogue ;  finally,  it  was  posi- 


DIFFUSE  PERITONITIS.  91 

tively  a  bacterial  infection,  although  the  post- 
mortem finding  of  bacteria  in  the  distant  folds  of 
the  peritoneum  is  not  proof  of  this ;  we  know  that 
during  the  terminal  agony  or  after  death  these 
may  wander  a  long  distance  from  the  perityphlitic 
focus.' '  [The  author  plays  so  fast  and  loose  with 
the  words,  "diffuse  peritonitis,' '  that  I  am  re- 
minded of  a  remark  made  to  me  several  years  ago 
by  a  society  lady  who  posed  as  a  pace-setter  in 
all  matters  pertaining  to  the  intricacies  of  what  one 
should  and  should  not  do.  The  subject  was  one 
that  I  did  not  know  much  about  at  that  time,  and 
upon  which  I  am  not  much  better  informed  at 
present.  It  was  on  diamonds.  I  complimented 
her  on  a  very  beautiful  sunburst.  She  took  the 
compliment  modestly,  of  course.  The  center  dia- 
mond was  large  and,  I  thought,  of  uncommon  bril- 
liancy, and  I  remarked,  "That  center  stone  prop- 
erly mounted  would  make  a  very  fine  solitaire." 
She  then  informed  me  that  she  once  owned  a  clus- 
ter of  solitaires. 

The  author  tells  us  that  at  first  the  diffuse 
peritonitis  probably  did  not  extend  beyond  the 
local  focus;  this  of  course  is  exactly  what  I  am 
contending  for  from  first  to  last  and  I  insist  that 
there  was  not  peritonitis  proper  until  the  occur- 
rence of  the  fatal  relapse. 

It  is  somewhat  surprising  that  this  article 
should  be  selected  to  represent  the  last  word  on 
this  subject,  when  the  author  builds  his  treatment 


92  APPENDICITIS. 

upon  diffuse  peritonitis ;  then  enters  into  a  lengthy 
analysis  and  explanation  of  symptoms  to  fit  the 
diagnosis  and  treatment  and  before  he  is  through 
with  the  subject  he  declares  that  the  diffusion  is 
confined  to  the  focus  of  infection. 

If  I  did  not  know  something  of  the  worth  of 
words  I  am  not  sure  but  such  an  excellent  expla- 
nation might  persuade  me!  If  I  did  not  know 
from  experience  that  all  this  is  theory,  beautiful 
theory,  it  might  be  very  hard  to  resist !] 

" After  the  symptoms  of  local  and  general 
inflammation  with  their  secondary  signs  in  the 
stomach  and  intestine  had  lasted  for  six  days,  sud- 
denly a  complete  change  took  place :  The  nervous, 
anxious,  extremely  distressed  patient  became 
feeble  and  scarcely  complained  at  all ;  his  formerly 
congested  face  was  pale  and  elongated,  the  nose 
pointed  and  cool ;  the  skin  lost  its  turgescence  and 
warmth  and  was  covered  with  a  cold  sweat;  the 
bodily  temperature  also  fell,  the  pulse  became 
small  and  frequent  but  remained  quite  regular,  the 
abdomen  became  softer  and  to  a  great  extent  lost 
its  sensitiveness ;  the  vomiting  decreased  to  a  few 
painless  attacks/ '  [wholly  due  to  the  opium  and 
morphine  given]  "and  singultus  disappeared:  A 
picture  which,  to  a  certain  extent,  is  a  combination 
of  collapse  and  narcosis  although  not  to  the  degree 
of  profound  loss  of  consciousness,  being  the  pic- 
ture of  an  intoxication  in  sharp  contrast  to  the 
preceding  febrile  state. ' ' 


WHY  HE  DIED.  93 

[That  is  exactly  what  I  stated  above — a  case 
of  narcotism.  How  is  it  possible  that  the  author, 
recognizing  the  narcotism,  feels  it  incumbent  to 
give  other  explanations?] 

"Just  as  the  affection  had  suddenly  devel- 
oped to  its  full  height  at  the  onset  of  the  disease, 
and  much  more  swiftly  than,  for  example,  is  the 
case  in  phlegmon  of  the  external  walls,  so  with 
extraordinary  rapidity  did  the  clinical  picture  as- 
sume a  new  type.  In  this  respect  we  must  consider 
the  very  great  area  of  the  peritoneal  folds,  their 
numerous  lymphstomata,  and  their  intimate  rela- 
tion to  the  circulation,  and  we  are  impressed  with 
the  fact  that  fluids  and  solubles,  as  well  as  formed 
products,  are  rapidly  absorbed  by  the  peritoneum. 
"Somewhat  less  rapidly  than  this,  but  never- 
theless in  the  course  of  a  few  hours,  another 
change  took  place,  a  favorable  turn  following  the 
rupture  of  pus  into  the  intestine.  Here  we  were 
dealing  with  a  well  known  and  familiar  phenome- 
non; if  this  occurs  in  the  peritoneum  the  effects 
are  particularly  well  marked ;  similarly  as  in  the 
case  of  a  phlegmon  which  rapidly  disappears  with 
the  discharge  of  pus  even  although  the  inflamma- 
tion extend  beyond  the  pus  focus,  the  symptoms 
of  diffuse  peritonitis  promptly  disappeared  after 
the  rupture.  Very  likely,  as  has  already  been 
stated,  the  symptoms  of  diffuse  peritonitis  in  the 
first  stages  of  the  disease  are  to  be  referred  to 
a  chemical  inflammation  of  the  serosa,  i.  e.,  one 


94  APPENDICITIS. 

due  to  toxins  and  without  the  ingress  of  bacteria; 
and  it  must  be  remembered  that  the  clinical  pic- 
ture of  this  chemical  peritonitis  cannot  be  differ- 
entiated from  that  of  the  severe  bacterial  form. 
With  the  rupture  of  the  abscess,  the  entrance  of 
poisons  into  the  free  peritoneal  cavity,  and  their 
resorption  by  the  extensive  peritoneal  surfaces, 
as  well  as  the  vomiting  and  the  intestinal  paral- 
ysis, ceased.  The  taking  of  nourishment  again  be- 
came possible. 

"The  point  of  rupture  formed  adhesions,  the 
natural  drainage  of  the  peritoneal  ichorous  focus 
ceased,  perhaps  a  new  influx  of  inflammatory 
material  from  the  perforated  appendix  also  took 
place.  There  was  a  fresh  relapse  of  the  local  peri- 
tonitis which  extended  beyond  the  boundaries  of 
the  limiting  adhesions,  and  permitted  the  invasion 
by  bacteria  of  the  free  abdominal  cavity.  This 
time  the  severe  toxic  picture  of  collapse  immedi- 
ately followed,  and  with  marked  decrease  in  car- 
diac strength  led  to  death. 

"Doubtless  the  patient  might  have  been  saved 
in  the  first  stages  of  the  disease  by  the  evacuation 
of  the  abscess;  the  incision  would  at  first  have 
acted  similarly  to  spontaneous  rupture  into  the 
intestine,  but  the  relapse  would  have  been  pre- 
vented by  permanent  drainage,  and  a  radical  cure 
might  have  been  brought  about  by  the  immediate 
or  subsequent  removal  of  the  appendix. 

' '  Opium,  no  doubt,  had  a  favorable  effect  upon 


INFLAMMATION.  95 

the  affection.  By  relieving  intestinal  irritability, 
and  by  bringing  about  a  mild  degree  of  narcosis, 
the  patient  was  kept  quiet  and  this  materially 
assisted  in  limiting  the  severe  perityphlic  sup- 
puration in  the  first  stage  of  the  disease. ' '  [All  of 
which  is  positively  not  true,  as  I  have  witnessed 
for  years.]  "If,  as  it  unfortunately  happened,  the 
point  of  rupture  had  not  immediately  closed  again, 
if  it  had  remained  open  until  suppuration  ceased 
and  contraction  and  healing  of  the  perforated  ap- 
pendix had  taken  place,  opium  would  have  been 
regarded  as  instrumental  in  saving  the  patient, 
and  unquestionably,  at  least  to  some  extent,  justly 
so.  Among  other  factors  in  the  treatment,  the 
relief  to  the  intestine  by  the  suspension  of  nour- 
ishment was  of  paramount  importance.  The  sub- 
cutaneous saline  infusion  had  an  obvious  but,  nat- 
urally, only  a  transitory  effect."   • 

The  subcutaneous  saline  infusion  is  another 
ridiculous  habit.  It  would  really  be  amusing  if  it 
were  not  so  tragic,  to  see  patients  driven  to  the 
edge  of  the  great  divide  and  then  see  the  innocent 
doctor  throw  out  an  impotent  life  line. 

The  absolute  innocence  displayed  by  this  pro- 
fessional man,  from  first  to  last,  his  belief  in  him- 
self and  the  mechanism  of  his  theory  and  practice 
exculpate  him  from  the  charge  of  carelessness, 
neglect  of  duty  or  even  that  he  didn't  know  what 
he  is  doing.  He  does  know  what  he  is  doing  in  a 
way.    He  works  as  exactly  as  a  Waltham  watch 


96  APPENDICITIS. 

and  he  thinks  about  as  much  as  the  stem  that 
winds  the  watch. 

I  cannot  agree  to  the  summing  up  of  this  case. 
There  was  not  at  any  time,  previous  to  the  relapse 
and  death  of  this  patient,  what  we  understand  as 
peritonitis.  A  post-mortem  examination  might 
have  shown  the  intra-peritoneal  covering,  of  that 
portion  of  the  cecum  involved  in  the  inflamma- 
tion, slightly  inflamed,  but  it  is  not  reasonable 
to  believe  that  the  inflammation  was  of  a  toxic 
character  unless  adhesive  inflammations  can  be  so 
called. 

Inflammation  is  always  the  same,  it  matters 
not  what  the  exciting  cause  may  be.  It  is  an  ex- 
aggerated physiological  process.  If  there  is  in- 
flammation of  any  part  of  the  body  it  means  that 
there  is  an  exaggeration  of  function.  Its  intensity 
will  be  in  keeping  with  the  exciting  cause.  If  the 
cause  is  intense  heat  or  cold,  or  a  corroding  acid 
or  alkali,  the  local  action  may  be  great  enough  to 
destroy  the  part ;  the  inflammation  following  will 
be  of  the  contiguous  structure  outside  of  the  kill- 
ing range  of  the  cause,  and  it  will  be  a  simple — 
non-toxic — inflammation  unless  the  secretions 
thrown  out  in  excess  of  the  reparative  need  are 
retained  by  dressings  or  prevented  in  some  other 
way  from  draining  away.  If  these  secretions  are 
kept  bound  on  the  raw  surface  by  dressings  until 
they  decompose — yes,  until  the  fermentation 
causes  germs — the  wound  will  become  infected, 


EXCITEMENT.  97 

and  to  what  extent  will  depend  upon  the  amount 
of  malpractice — carelessness  or  ignorance — to 
which  the  case  is  subjected. 

If  the  inflammation  is  caused  by  decomposi- 
tion or  a  toxic  agent,  the  extent  of  the  process 
will  depend  upon  the  integrity  of  the  part  infected 
and  the  state  of  the  general  health,  also  upon  the 
local  environment — such  as  pressure  interfering 
with  the  circulation  of  the  blood. 

In  this  fatal  case  there  was  the  constitutional 
derangement  and  the  toxic  state  of  the  alimentary 
canal ;  then  there  was  the  exciting  cause,  sufficient 
to  create  a  local  infection,  the  symptoms  of  which 
were  given  at  the  beginning  of  this  description, 
and  which  lasted  for  a  few  days;  during  which 
time  the  patient,  no  doubt,  was  eating  and  possibly 
taking  home  remedies  to  move  the  bowels,  etc. 
These  preliminary  symptoms  were  followed  by  a 
severe  pain  in  the  right  lower  abdominal  region, 
followed  with  chills,  fever,  nausea,  vomiting  and 
later  by  painful  movements  from  the  bowels,  small 
in  character,  and  soon  after  this  distention  of  the 
bowels  from  gas. 

During  the  few  days  of  preliminary  symp- 
toms nature  was  going  through  the  usual  prepara- 
tion of  fixing  the  parts.  The  muscles  were  becom- 
ing rigid,  which  is  one  of  nature's  plans  for  pro- 
tecting an  inflamed  part ;  the  infection  was  strik- 
ing deeper  and  arousing  all  the  defenses.  Pos- 
sibly there  had  been  a  local  inflammation  of  long 


98  APPENDICITIS. 

standing,  gradually  degenerating  into  a  fecal  nicer, 
which  means  that  there  was  a  spot  of  ulceration 
deep  enough  for  fecal  accumulation  and  the  ac- 
cumulation created  fresh  infection,  which  lighted 
up  an  active  inflammation  setting  all  the  parts  into 
defensive  activity.  The  muscles  of  the  abdomen, 
the  bowels  and  all  involved  and  contiguous  parts 
became  set  or  fixed;  and  when  this  rigid  state 
became  established,  the  bowels  below  the  cecum 
refused  to  receive  the  contents  of  the  small  intes- 
tine ;  hence  when  the  peristaltic  movement  started 
at  the  head  of  the  small  intestine  it  found  that 
an  embargo  had  been  laid  on  the  cecum  and  lower 
bowels  so  that  nothing  could  pass.  This  embargo 
took  effect  "about  midday;  he  was  seized  with 
very  severe  pain."  What  was  this  pain!  What 
is  the  pain  that  always  attends  obstruction  of 
any  kind?  It  is  the  desire  for  the  bowels  to  move 
when  they  are  unable,  on  account  of  the  stoppage, 
to  do  so.  Is  there  a  reader  who  can't  conceive  of 
the  terrible  suffering  that  must  come  from  such 
a  state  of  the  bowels?  The  pain  is  not  from  the 
spot  of  inflammation,  or  ulceration,  or  the  forming 
abscess,  whichever  is  the  exciting  cause  of  all  this 
trouble ;  for,  if  it  were,  the  pain  would  not  stop  in 
three  days,  or  after  the  patient  has  been  fasted 
long  enough  for  the  peristaltic  movements  to  sub- 
side. No,  the  local  inflammation  is  not  sufficient 
within  itself  to  cause  any  more  pain  than  this 
patient  had  the  few  days  before  he  went  to  bed; 


IMPROPER  TREATMENT.  99 

it  takes  obstruction  to  bring  suffering,  and  even 
obstruction  will  not  cause  pain  per  se,  for  this  is 
proven  in  all  cases  rightly  treated.  As  soon  as 
the  stomach  and  upper  bowels  are  rested  from 
food  and  drugs,  all  pain  is  gone  and  will  never 
return  unless  the  patient  is  badly  handled. 

In  this  case  opium  and  morphine  were  given ; 
this  was  very  bad  treatment,  for  these  drugs 
always  produce  nausea  and  vomiting,  exactly  what 
was  not  desired  because  of  the  evil  effect  the 
retching  had  on  the  forming  abscess.  It  is  true 
that  these  cases  frequently  vomit  the  first  three 
days  after  the  obstruction,  but  there  is  practically 
no  danger  from  retching  that  early  in  the  disease. 
Again,  the  opium  masked  the  case  dreadfully ;  for 
it  produced  vomiting  at  that  stage  of  the  case 
when  there  should  have  been  no  trouble  with  the 
stomach  at  all,  and  induced  a  tympanites  that  was 
mistaken  for  the  same  state  brought  on  by  peri- 
tonitis. 

In  this  case  the  doctor  was  in  a  mental  mist 
from  the  beginning  to  the  end;  notwithstanding 
he  was  so  confident  that  he  knew  all  about  his 
patient,  that  he  has  given  the  case  a  careful  sum- 
ming up  so  that  it  may  be  put  with  the  medical 
classics. 

The  doctor  is  in  error  when  he  gives  the  name 
of  " Acute,  Diffuse  Peritonitis."  The  case  could 
not  have  been  peritoneal  perforation  at  the  start, 
for  the  symptoms  do  not  justify  the  diagnosis. 


100  APPENDICITIS. 

A  perforation  causing  diffuse  peritonitis  so  early 
would  have  a  higher  pulse  and  temperature,  and 
death  would  have  followed  within  a  few  hours. 

I  can  believe  that  there  might  have  been  an 
ulcer  extending  to  the  peritoneal  covering,  and 
this  set  up  local  peritonitis;  but  there  was  not  at 
any  time  before  the  fatal  relapse,  a  toxic  inflam- 
mation within  the  peritoneal  cavity;  hence  there 
was  not  diffuse  peritonitis,  and  there  could  not 
have  been  without  complete  perforation  which 
would  have  ended  the  case  in  death  very  soon. 

In  this  case  the  point  of  infection  was  walled 
in,  as  all  such  cases  are,  with  exudates  and 
whether  the  appendix  was  primarily  affected  or 
not  doesn't  matter;  it  was  within  this  enclosure 
and  found  to  be  ruptured,  which  is  common;  but 
its  rupture  was  of  no  consequence  because  the 
escaped  contents  were  in  the  abscess  cavity  that 
finally  emptied  into  the  cecum,  the  natural  outlet 
in  all  these  cases  if  they  are  left  to  nature  and  not 
officiously  fingered — thumbed  and  punched  to 
death. 

The  distinction  drawn  by  this  author  between 
toxic  and  bacterial  peritonitis  is,  to  my  mind,  a 
distinction  without  a  difference. 

In  this  case  the  tympanites  following  the  ob- 
struction was  due  to  the  fact  that  the  gas  in  the 
bowels  was  retained  for  a  few  days  because  of  the 
completeness  of  the  obstruction,  and  would  have 
passed  off  in  three  days  had  it  not  been  for  the 


A  SIMILAR  CASE.  101 

paralyzing  effect  of  the  opium;  hence  the  disten- 
tion that  came  from  gas  was  succeeded  by  the  dis- 
tention peculiar  to  opium  and  caused  the  doctor 
to  believe  that  he  had  a  case  of  diffuse  peritonitis 
when,  in  fact,  he  had  a  case  of  gas  distention  due 
to  morphine  paralysis.  The  morphine  directly 
and  indirectly  weakened  the  heart.  The  distention 
of  the  bowels  was  a  constant  interference.  The 
pulse  at  the  start  was  fine  at  112,  but  in  six  days 
it  had  increased  to  140  and  finally  reached  160. 


102  APPENDICITIS. 


CHAPTEE  VIII. 

The  following  case  comes  to  my  mind,  for 
some  of  the  initial  symptoms  are  similar  to  those 
of  the  case  just  described: 

M.  B.,  age  42,  farmer,  was  taken  sick  with 
the  usual  symptoms  of  appendicitis  as  near  as  I 
could  get  the  history  from  his  wife,  who  was  his 
nurse.  He  lived  twenty  miles  from  Denver.  When 
he  was  taken  sick  he  called  a  local  physician  who 
treated  him  for  bilious  diarrhea.  The  drugs  used, 
as  near  as  the  wife  could  remember,  were  small 
doses  of  calomel  followed  with  salts  to  correct  the 
liver,  morphine  for  pain,  and  bismuth  and  pepsin 
for  digestion  and  diarrhea,  and  quinine  to  break 
the  fever;  also  hot  applications  on  the  bowels. 
The  pain  was  so  great  that  morphine  had  been 
given  quite  freely. 

At  the  end  of  one  week  the  sick  man,  being 
no  better,  declared  that  he  would  go  to  Denver 
and  consult  another  physician.  When  he  told  his 
physician  what  his  intentions  were,  the  doctor 
advised  him  not  to  attempt  the  trip  himself,  for  he 
was  too  sick,  but  to  send  for  the  physician.  The 
sick  man  was  wilful  and  forceful,  and  he  was  also 
afraid  of  the  cost;  and,  being  a  plucky  fellow,  he 
declared  that  he  could  go  just  as  well  as  not  and 
that  he  would  and  he  did. 


SYMPTOMS.  103 

His  wife  was  a  large,  strong  woman  and  gave 
him  valuable  assistance,  but  I  never  have  under- 
stood how  it  was  possible  for  so  sick  a  man  to 
make  the  journey  from  his  home  to  my  office.  He 
was  obliged  to  help  himself  a  great  deal  in  climb- 
ing in  and  out  of  ordinary  conveyances  to  reach 
the  train  and,  when  in  Denver,  with  his  wife's 
assistance,  he  walked  a  half  block  to  the  street 
car ;  then  from  the  car  to  my  office  he  was  obliged 
to  walk  one  block  and  at  last  climb  one  flight  of 
stairs.  When  they  came  into  my  office  the  wife 
was  almost  carrying  him.  I  saw  at  a  glance  that 
he  was  a  desperately  sick  man,  and  before  I  at- 
tempted to  examine  him  I  had  him  lie  down  for 
a  while. 

He  had  no  history  of  any  previous  sickness; 
he  had  always  been  very  healthy,  and  his  life  had 
been  spent  in  hard  work  in  the  open  air. 

The  general  appearance  of  the  man  was  that 
of  one  suffering  from  diffuse  peritonitis.  The  ab- 
domen was  enormously  distended;  this  symptom 
more  than  any  other  caused  me  to  fear  and  won- 
der— fear  that  rupture  would  take  place  before  he 
could  be  put  to  bed,  and  wonder  how  it  was  pos- 
sible for  a  man  to  be  out  of  bed  and  go  through 
what  he  had  gone  through  that  morning  without 
causing  a  fatal  injury  of  some  kind.  The  disten- 
tion, I  was  informed,  had  been  gradually  coming 
on  from  the  first,  and  he  had  been  given  morphine 
to  control  the  pain  from  the  first  day  of  his  ill- 


104  APPENDICITIS. 

ness.  When  they  gave  me  this  information  I 
knew  that  the  tympanites  was  due  to  narcotic 
paralysis,  instead  of  coming  from  perforative, 
septic  peritonitis,  as  the  general  appearance  and 
symptoms  indicated.  This  reasoning  gave  me 
hope  in  spite  of  the  formidable  appearance  of  the 
case. 

The  pulse  was  130,  temperature  102°  F.,  in 
the  forenoon ;  he  had  been  troubled  with  nausea  a 
great  deal,  but  with  the  exception  of  one  or  two 
vomiting  spells,  the  first  and  second  day,  the 
nausea  did  not  often  cause  retching.  The  mouth 
and  lips  were  dry,  tongue  coated,  bad  taste  in 
mouth  and  breath  very  offensive. 

The  reason  there,  had  not  been  more  vomiting 
in  this  case  was  because  there  was  diarrhea  at  first 
and  not  quite  so  much  locked  up  fecal  matter  as 
common.  The  bowels  had  been  relieved  of  the 
usual  accumulation  more  than  is  common  to  the 
majority  of  such  diseases  before  the  swelling  and 
fixation  had  become  established. 

There  is  a  small  percentage  of  people  who 
are  not  quite  so  irritable  as  others;  in  these  the 
contraction,  constriction  or  fixation — the  embargo 
laid  on  these  parts  by  nature  in  her  conservative 
effort  at  preventing  movement — is  not  established 
quite  so  early,  and  the  efforts  on  the  part  of 
doctors  to  force  a  movement  are  more  successful 
in  cleaning  out  a  part  of  the  accumulation;  or 
there  may  come  a  diarrhea  from  the  putrefactive 


GENERAL  TREATMENT.  105 

poisoning  which  is  causing  the  infection  of  the 
cecum  or  appendix  and  leading  to  abscess,  and 
this  causes  a  partial  cleaning  out  before  fixation 
is  established;  in  these  cases  there  is  never  so 
much  vomiting  nor  nausea,  neither  do  they  suffer 
so  much  pain  for  there  is  not  the  usual  accumula- 
tion in  the  alimentary  canal  to  excite  the  peri- 
staltic movement. 

The  history  that  the  patient  and  his  wife  gave 
me  from  memory  was  that  the  urine  had  been 
scant,  and  at  times  painful  to  pass.  There  had 
been  from  the  start  severe  pain  in  the  lower 
bowels,  but  neither  the  patient  nor  his  wife  could 
remember  if  there  had  been  more  pain  on  right, 
lower,  frontal  region  than  anywhere  else;  they 
both  declared  that  the  pain  was  all  through  the 
bowels  and  that  there  was  much  bearing  down 
like  unto  the  pain  of  a  diarrhea. 

Breathing  was  shallow,  of  course;  it  never  is 
otherwise  in  severe  abdominal  distention. 

I  scarcely  touched  the  abdomen,  for  I  knew 
I  dare  not  press,  in  percussing,  enough  to  dis- 
tinguish any  sound  except  the  tympanitic.  It  has 
never  been  my  custom  to  allow  my  curiosity  to 
run  away  with  my  judgment,  and  cause  me  to 
make  needless  examinations. 

All  examinations  are  needless  when,  it  mat- 
ters not  what  the  diagnosis  can  or  must  be,  the 
treatment  will  be  the  same.  All  possible  bowel 
troubles  which  present  the  same  general  symp- 


106  APPENDICITIS. 

toms  of  the  disease  I  am  here  describing,  must 
receive  a  like  general  treatment.  This  being  true, 
it  matters  not  what  the  difference  is,  there  cannot 
be  a  variation  requiring  a  bimanual  examination 
to  differentiate  it  that  will  justify  the  risk.  All 
examinations  are  needless  and  criminal  when  there 
is  a  possibility  of  rupturing  an  abscess.  Espe- 
cially is  this  true  when  it  is  a  positive  fact  that  all 
typhlitic  and  appendicular  abscesses  will  open 
into  the  bowels  if  allowed  to  do  so. 

In  this  case  I  reasoned  as  follows :  This  must 
be  a  case  of  abscess,  for  the  signs  of  obstruction 
are  not  those  of  complete  obstruction,  such  as  are 
seen  in  hernias,  volvulus,  constricting  bands  and 
many  other  causes  not  necessary  to  mention.  If 
there  were  complete  obstruction  there  would  be 
increasing  nausea  and  vomiting,  ending  in  collapse 
and  death.  This  tympanites  cannot  be  from  peri- 
tonitis for  perforation  would  be  necessary  to  cause 
it  and  nothing  would  stop  the  progress  after  it 
had  once  started  except  to  open  the  cavity,  wash 
and  drain.  Hence  this  cannot  be  peritonitis,  for 
there  has  been  no  operation  and  the  patient  still 
lives.  It  can  be  distention  from  the  effects  of 
morphine,  but  there  must  be  more  than  morphine 
paralysis,  for  there  is  a  temperature  of  102°  to 
103°  F.,  and  there  has  been,  so  the  wife  says,  a 
temperature  of  104°  F.  The  pulse  rate  being  130 
does  not  indicate  fever  nor  exhaustion,  and  is  not 
in  keeping    with    the    temperature  nor  physical 


SUBSIDENCE  OF  SYMPTOMS.  107 

strength,  hence  the  rapidity  must  be  partly  due  to 
pressure  on  the  diaphragm  from  the  gas  disten- 
tion and  partly  from  the  paralyzing  effect  that 
opium  has  on  the  heart. 

The  professional  reader  will  see  that  I  have 
by  my  analysis  eliminated  much  of  the  f  ormidable- 
ness  that  the  physical  appearance  gives  to  this 
case,  but  I  would  not  have  you  believe  that  this 
man  was  not  a  desperately  sick  man  even  if  I  have 
accounted  for  the  dangerous  symptoms.  The  fact 
is,  if  the  pronounced  symptoms  had  been  what 
they  appeared  to  be,  the  man  would  have  been 
saved  his  trip  to  me,  for  he  would  have  been  dead. 

The  farmer  had  learned  from  experience  that 
the  less  he  put  in  his  stomach  the  better  he  felt ; 
hence,  for  a  day  or  two  before  he  left  his  home  to 
consult  me,  he  had  refused  food  and  drugs  and 
had  taken  very  little  water. 

After  giving  t1c\&  sick  man  a  rest  in  my  office 
I  had  his  wife  take  him  to  the  home  of  a  friend 
with  whom  they  had  arranged  to  stay  while  in  the 
city.  In  a  few  hours  I  visited  him  and  made  the 
following  prescriptions  and  proscriptions :  Posi- 
tively no  food,  not  one  teaspoonful  of  anything 
except  water.  An  enema  of  half  a  gallon  of  tepid 
water  to  be  used  once  each  day  for  the  purpose  of 
clearing  out  the  bowels  below  the  constriction,  and 
I  advised  against  violence — rough  handling.  A 
hot  water  jug  to  the  feet,  ice  to  the  abdomen,  all 
the  fresh  air  possible  in  his  bedroom  and  absolute 


108  APPENDICITIS. 

quiet.  If  nauseated,  enough  water  to  control 
thirst  was  to  be  used  by  enema;  if  the  stomach 
was  all  right  all  the  water  desired  by  mouth. 

I  called  the  second  day ;  the  patient  had  slept 
some — he  thought  about  three  hours  of  broken 
rest — feeling  fairly  comfortable;  pulse  120,  tem- 
perature 101°  F.,  at  9:00  a.  m.;  102°  F.,  at  5:00 
p.  m.  Third  day:  Temperature  100°  F.,  at  9:00 
a.  m. ;  101°  F.  at  5 :00  p.  m. ;  one-third  of  the  tym- 
panites gone;  slept  six  hours;  hungry  and  de- 
manding food.  I  said,  "No,  you  get  no  food  until 
the  bowels  move.,,  The  ice  was  taken  off  the 
bowels;  hot  cloths  were  substituted. 

The  fourth  day  the  temperature  in  the  morn- 
ing was  100°  F. ;  in  the  afternoon  101°  F.,  pulse 
100;  slept  well,  hungry,  bowel  distention  reduced 
fifty  per  cent.  I  touched  him  very  lightly  and 
found  enough  to  confirm  my  diagnosis  of  typhlitic 
abscess;  this  was  the  first  time  I  had  felt  that 
I  was  justified  in  attempting  to  confirm  my  suspi- 
cions, and  even  this  examination  could  not  be 
called  a  palpation,  for  I  put  no  weight  upon  the 
abdomen.  The  patient  was  very  dissatisfied  be- 
cause I  would  not  allow  him  food.  I  said,  "No, 
you  can't  eat  until  your  bowels  move."  "How 
soon  will  they  move?"  he  asked  in  an  irritating 
and  ungracious  manner,  to  which  I  replied,  ' '  Your 
God  only  knows,  and  He  won't  tell." 

Fifth  day  about  the  same,  a  little  better ;  very 
ugly  because  I  would  not  allow  him  food.  He  said : 


COMFORTABLE  SICKNESS.        p  109 

"I  don't  believe  there  is  anything  the  matter  with 
me;  you  are  holding  me  down." 

Sixth  day  about  the  same,  feeling  fine,  sleep- 
ing fine  and  starving  to  death.  He  made  himself 
so  unpleasant  by  his  clamoring  for  food  that  I 
permitted  his  wife  to  give  him  a  half  dozen  Tokay 
grapes.  He  had  scarcely  swallowed  the  sixth  when 
he  had  all  the  pain  he  wanted.  His  wife  came  to 
my  office  in  great  excitement:  "Doctor,  please 
come  at  once  to  see  my  husband ;  he  is  much  worse, 
he  is  in  agony  with  his  bowels. ' '  My  answer  was : 
"Go  back  and  renew  your  hot  applications  to  the 
bowels  and  tell  your  husband  I  permitted  him  to 
eat  the  grapes  because  he  had  been  so  unkind  and 
ungrateful  for  the  comfort  that  had  been  given 
him;  tell  him  that  I  knew  the  grapes  would  give 
him  pain  and  that  the  pain  will  not  wear  off  en- 
tirely for  twelve  hours,  and  that  I  will  not  see  him 
before  tomorrow  morning." 

I  called  as  I  agreed  to  do  the  next  day,  the 
seventh  day  since  the  case  came  under  my  man- 
agement, and  the  fourteenth  day  from  the  begin- 
ning of  the  disease.  The  sick  man  was  out  of 
humor.  To  my  question,  "Would  you  like  some- 
thing to  eat?"  he  drawled,  "Na-a-aw!  I  never 
intend  to  eat  any  more ;  but  I  would  like  to  know 
when  my  bowels  are  going  to  move."  Of  course 
I  could  not  tell  him  any  more  than  I  had  told  him 
before,  namely,  that    under   such   circumstances 


110  APPENDICITIS. 

they  usually  require  from  fourteen  to  twenty- 
eight  days. 

From  this  time  on  every  day  was  much  the 
same ;  no  elevation  in  temperature,  and  the  pulse 
ranged  from  eighty  to  occasionally  one  hundred; 
no  pain,  sleep  good,  that  is,  as  good  as  people  gen- 
erally sleep  who  are  on  a  continuous  fast — under 
a  continuous  fast  the  sleep  is  good  but  not  heavy 
nor  long  at  a  time. 

It  is  a  fact  that  when  these  cases  are  properly 
handled  they  are  not  sick  after  the  first  week ;  they 
do  not  look  sick;  they  get  to  thinking  that  it  is 
folly  to  stay  in  bed  and  live  without  food,  and  of 
course  their  neighbors  know  that  there  isn't  any- 
thing the  matter  with  them;  that  the  doctor  is 
starving  them  to  death.  Quite  a  number  of  my 
patients  have  brought  themselves  near  death's 
door  from  disobeying  instructions  and  taking  the 
advice  of  knowing  neighbors.  They  were  per- 
suaded to  ' '  eat ' ' — ' '  eat  all  you  want,  for  the  doc- 
tor will  not  know  it." 

This  is  one  disease  that  will  give  the  disloy- 
alty of  the  patient  away  every  time. 

On  the  morning  of  the  nineteenth  day  of  his 
sickness,  and  the  twelfth  day  of  my  services,  I 
called  to  see  the  sick  man,  and  before  I  could  ask 
him  a  question  he  shot  out  his  hand  toward  me 
and  exclaimed,  ' '  My  bowels  moved  at  four  o  'clock 
this  morning !  I  want  a  beefsteak  for  my  break- 
fast ! ' '    I  congratulated  him  on  his  fine  condition 


RECOVERY.  Ill 

and  ordered  him  a  dish  of  mutton  broth.  This 
disgusted  him  thoroughly,  and  his  reply  was  in 
kind:  "A  dish  of  broth!  After  fasting  two  days 
on  my  own  prescription,  and  then  twelve  days  on 
yours,  I  am  to  be  rewarded  with  a  dish  of  broth. ' ' 
I  explained  that  he  had  a  large  abscess  cavity  that 
would  require  several  days  to  empty,  collapse  and 
draw  together,  and  if  he  should  eat  solid  foods  too 
soon  he  would  run  the  risk  of  cultivating  chronic 
appendicitis — recurring  appendicitis.  I  advised 
him  to  live  on  liquid  foods  for  three  or  four  days, 
and  after  that  he  could  have  solid  foods  if  he 
would  practice  thorough  mastication. 

The  action  from  the  bowels  had  been  saved 
for  me ;  there  was  an  ordinary  chamber  half  full ; 
it  looked  to  me  like  at  least  a  half  gallon  of  fecal 
matter,  pus  and  blood ;  it  was  dreadfully  offensive. 
Six  hours  after  the  first  movement  I  was  informed 
that  he  had  another  movement  very  similar  in 
quantity  and  consistency ;  this  movement  I  did  not 
see,  for  I  did  not  visit  the  man  after  the  morning 
of  the  nineteenth.  He  left  for  his  home  on  the 
morning  of  the  twenty-third  and  has  had  excellent 
health  ever  since. 

If  this  man  had  been  subjected  to  daily  exami- 
nations, food  and  drugs,  would  he  have  presented 
the  same  symptoms !  Indeed  the  tympanites  alone 
would  have  killed  him.  Was  his  case  diffuse  peri- 
tonitis? No!  For  if  there  had  been  intra-peri- 
toneal  infection  in  the  first  place,  it  would  have 


112  APPENDICITIS. 

indicated  perforation,  and  then,  without  the  open- 
ing up  of  the  peritoneal  cavity,  washing  and  drain- 
ing, there  would  have  been  a  funeral. 

The  following  is  a  similar  case  except  that  the 
woman  came  into  my  hands  the  first  day  of  her 
sickness.  Her  symptoms  were:  Nausea,  vomiting 
and  pain  all  over  the  bowels  as  she  said — as  much 
pain  in  one  place  as  another — temperature  102° 
F.,  which  ran  up  to  103°  F.  in  the  p.  m. ;  pulse  110, 
and  a  history  of  constipation.  She  had  several 
movements  from  the  bowels  through  the  night  be- 
fore I  was  called  in  the  morning.  The  movements 
were  small  and  accompanied  with  much  griping; 
the  patient  said  that  if  she  could  have  a  good 
cleaning  out  of  the  bowels  she  felt  that  she  would 
be  well.  I  informed  her  that  she  had  appendicitis 
and  that  she  would  be  compelled  to  remain  very 
quiet  in  bed,  with  ice  applied  locally  until  the  tem- 
perature was  reduced  to  101°  F.,  or  less,  and  then 
substitute  hot  applications.  For  the  pain  I  had 
her  stay  in  the  hot  bath  until  relieved,  and  when 
the  pain  returned  she  was  to  go  to  the  bath  again. 
The  bath  water  was  ordered  to  be  used  as  hot  as 
possible.  Every  night  an  enema  of  warm  water. 
The  treatment  did  not  vary  from  the  farmer  *s  and 
the  results  were  the  same — her  bowels  moved  on 
the  nineteenth  day;  the  consistency  and  amount 
were  about  the  same,  and  I  had  her  exercise  care 
about  her  eating  for  a  week  after  the  abscess  dis- 
charged.   From  the  end  of  the  first  week  of  her 


COMPARISONS.  113 

sickness  until  the  abscess  broke  she  expressed  her- 
self freely  that  she  did  not  believe  there  was  any- 
thing the  matter,  and  that  going  without  food 
when  one  felt  well  was  foolish;  however,  she 
obeyed  and  had  no  suffering. 

A  son  of  the  woman  whose  case  I  have  re- 
ported above  was  taken  down  the  same  way  one 
year  after.  I  explained  the  situation  and  told  the 
young  man  that  he  must  keep  quiet  and  go  without 
food  just  as  his  mother  did  the  year  before.  I 
did  not  think  it  necessary  to  visit  him  very  often, 
for  he  knew  how  his  mother  was  treated,  besides 
she  was  with  him  to  advise. 

Within  three  days  he  was  comfortable,  and 
remained  so  until  about  the  seventh  or  eighth  day, 
when  he  decided  he  would  take  a  glass  of  milk  and 
not  say  anything  to  me  about  it.  He  took  the  milk 
and  was  writhing  in  pain  within  two  hours.  I  was 
sent  for,  and  of  course  asked  what  he  had  eaten, 
whereupon  he  told  me  that  he  had  taken  milk. 
Within  twenty-four  hours  he  was  easy  and  cured 
of  his  desire  to  eat  until  ready  for  it.  This  case 
terminated  by  rupture  of  the  abscess  on  the  fif- 
teenth day. 

Neither  of  these  cases  had  any  tympanites 
worth  mentioning.  All  cases  that  I  have  ever  seen 
with  great  bowel  distention  are  those  coming  into 
my  care  after  being  subjected  to  the  usual  feeding 
and  medicating. 

Now  we  will  go  over  Dr.  Vierordt's  case  in 


114  APPENDICITIS. 

connection  with  mine  and  see  if  his  case  of  diffuse 
peritonitis  is  not  about  as  near  like  my  case  as 
it  is  possible  to  have  two  cases. 

His  patient  was  a  merchant  31  years  old,  mine 
a  farmer  42  years  old.  There  is  a  difference  in 
these  two  men,  caused  by  their  occupations.  The 
merchant  could  not  have  made  the  trip  to  my  office 
as  did  the  farmer,  for  several  reasons:  First, 
merchants  are  pampered ;  they  are  not  used  to  dis- 
comfort ;  they  are  not  used  to  waiting  upon  them- 
selves as  country  men  are.  When  they  are  sick 
they  send  for  the  doctor;  the  farmer  goes  to  the 
doctor.  The  merchant  has  learned  the  habit  of 
spending  his  money  and  the  farmer  has  learned 
the  habit  of  saving  his,  and  perhaps  that  one  state- 
ment is  enough  for  the  discerning. 

The  merchant  was  too  sick  to  make  such  a 
trip  and  he  knew  it.  The  farmer  was  too  sick  to 
make  the  trip  and  he  didn't  know  it.  This  is  the 
vital  difference  between  these  two  cases. 

The  merchant  was  tympanitic  from  the  first 
day  of  his  prostration,  which  is  not  usual.  On 
the  fourth  day  his  temperature  was  104°  F.,  pulse 
120  to  136,  mind  clear  but  anxious.  His  lesser 
symptoms  were  about  like  the  farmer's,  with  the 
exception  that  the  merchant  had  been  given  more 
narcotics  and  presented  more  of  the  dorsal  decu- 
bitus than  the  farmer.  Laymen,  the  plain  every- 
day meaning  of  dorsal  decubitus  is  lying  on  the 
back.    In  low  forms  of  disease  it  is  looked  upon 


OBSTRUCTION.  115 

as  an  unfavorable  symptom.  Where  much  mor- 
phine has  been  given  it  denotes  prostration  pecu- 
liar to  the  drug.  My  patient  was  on  his  back  for 
several  days,  because  it  is  impossible  for  a  patient 
to  stay  on  either  side  while  suffering  from  severe 
tympanites. 

On  the  sixth  day  the  merchant's  pulse  was 
140  and  the  temperature  101.3°  F.,  which  proves, 
if  nothing  else  does,  that  he  did  not  have  diffuse 
peritonitis,  for  it  is  impossible  for  a  patient  to 
have  acute,  diffuse  peritonitis,  be  drugged  and 
fed,  and  go  through  the  daily  physical  examina- 
tions such  as  he  was  put  through,  and  on  the  day 
before  the  abscess  breaks  into  the  bowels  show  a 
temperature  of  101.3°  F.  The  pulse  counts  for 
nothing  in  such  a  case  as  this ;  I  did  not  look  upon 
the  farmer's  pulse  as  indicative  of  any  serious 
state,  for  I  knew  the  opium  had  caused  it.  If  the 
pulse  of  either  the  merchant  or  the  farmer  had 
been  due  to  peritonitis  death  would  have  ended 
either  one  before  his  abscess  had  broken.  In  fact 
diffuse  peritonitis  comes  from  perforation  with 
discharge  of  the  abscess  contents  into  the  peri- 
toneal cavity,  and  it  always  spells  death. 

When  vomiting  recurs,  or  continues  after  the 
third  day,  there  is  malpractice,  or  there  is  a 
serious  complication,  or  there  is  a  mistaken  diag- 
nosis. 

It  is  well  to  get  this  one  fact  well  in  mind, 
namely,  appendicular  and  typhlitic  abscesses  are 


116  APPENDICITIS. 

not  accompanied  with  complete  obstruction ;  hence, 
when  the  symptoms  are  so  profound  as  to  point 
to  absolute  obstruction,  no  delay  should  be  made 
in  having  the  abdomen  opened  and  the  obstruction, 
whatever  it  is,  should  be  removed  at  once. 

The  fact  that  the  bowels  do  not  move  in  from 
twelve  to  twenty-one  days  should  not  be  looked 
upon  as  total  obstruction.  What  obstruction  there 
is  is  due  to  fixation  of  the  parts  and  is  truly  a 
physiological  rest — it  is  on  the  order  of  the  fixa- 
tion of  an  inflamed  joint — the  joint  appears  to  be 
anchylosed,  but  as  soon  as  the  pain  is  gone  it 
becomes  as  movable  as  ever. 

Again,  if  the  case  is  really  obstruction  it  will 
grow  worse  daily  even  if  my  plan  of  treatment — 
absolute  rest  from  everything — is  carried  out  to 
the  letter. 

There  is  not  any  danger  of  the  abscess  open- 
ing anywhere  except  into  the  bowels,  for  that  is 
in  the  line  of  least  resistance  and,  if  it  fails  to 
do  so,  it  is  because  it  is  badly  managed. 


PROPER  TREATMENT.  117 


CHAPTER  IX. 


I  have  appendicitis ;  what  shall  I  do  to  be 
saved?  Don't  eat  anything  until  well.  Use  a 
stomach  tube  and  wash  out  the  stomach ;  then  use 
a  fountain  syringe  and  wash  out  the  bowels ;  take  a 
hot  bath  as  hot  as  can  be  borne,  and  stay  in  the 
tub  until  all  the  pain  is  gone,  or  as  long  as  possi- 
ble ;  then  go  to  bed,  put  ice  on  the  bowels  and  keep 
it  on  until  the  temperature  is  reduced  to  101°  F., 
then  apply  hot  applications  or  poultices  and  con- 
tinue the  poulticing  until  the  bow  els  move,  and  the 
bowels  will  not  move  until  the  abscess  breaks. 

Use  an  enema  every  night  as  a  routine,  and 
drink  all  the  water  desired,  when  there  is  no 
nausea. 

Don't  manipulate  the  forming  abscess,  nor 
allow  anyone  else  to  do  so. 

If  you  are  really  in  doubt  about  what  you 
have,  think  over  what  I  have  written  about 
strangulation  or  positive  obstruction,  and  if  you 
think  you  have  it,  send  for  the  best  physician  you 
know  and  get  his  opinion  of  whether  you  have 
obstruction  or  not,  but  don't  allow  him  to  burst  an 
abscess  with  his  manipulations!  For,  my  word 
for  it,  if  he  can 't  weigh  symptoms  and  tell  whether 
or  not  you  have  complete  obstruction  without 
punching  holes  in  you  with  his  bimanual  manipu- 
lation, neither  would  he  be  able  to  do  so  after  ex- 
amining you. 


US  APPENDICITIS. 

I  do  not  say  this  because  I  like  to  make  it 
hard  for  doctors,  but  I  prefer  staying  the  heavy 
hand  of  the  doctor  to  keeping  still  and  allowing 
him  unwittingly  to  kill  his  patient. 

First  of  all  wash  the  stomach  out  with  a 
syphon  tube,  then  see  to  it  that  nothing  but  water 
goes  into  the  stomach  until  the  bowels  move. 

I  put  my  cases  on  a  complete  fast,  give  no 
drugs,  apply  ice  to  the  region  of  the  appendix, 
keep  the  feet  warm,  and  keep  the  patient  in  an 
atmosphere  of  hope  and  belief  in  his  recovery,  and 
a  recovery  always  follows.  I  prescribe  an  enema 
of  warm  water  once  or  twice  daily,  getting  all  the 
water  possible  into  the  bowels. 

These  patients  are  so  comfortable  after  the 
second  or  third  day  that  it  is  hard  to  make  them 
or  their  friends  believe  that  they  have  appendi- 
citis. People  are  so  afraid  that  they  will  starve 
to  death  if  they  have  no  food  for  a  few  days  that 
they  make  haste  to  get  put  on  a  killing  treatment 
rather  than  run  any  risk.  This  fear  is  absurd. 
Physicians  are  largely  to  blame  for  this  popular 
fear,  for  those  who  do  not  feed  by  mouth  still  have 
the  idea  that  their  patients  must  have  nourish- 
ment, so  they  feed  by  rectum.  This  is  also  absurd. 
What  the  patient  needs  is  rest,  and  the  more  com- 
plete the  rest  the  quicker  the  recovery.  Give  the 
patient  all  the  water  he  wants. 

The  bowels  will  move  in  fourteen  to  twenty- 
eight  days  from  the  beginning  of  the  attack.    Then 


SURGICAL  MANIA.  119 

the  fast  can  be  broken  by  giving  a  glass  of  hot 
milk,  which  is  to  be  chewed  well,  or  given  in  the 
form  of  junket ;  this  is  to  be  repeated  three  times 
a  day  for  a  week,  or  give  the  milk  twice  a  day 
and  a  plate  of  mutton  broth  for  the  third  meal. 
I  do  not  give  solid  food  because  there  is  a  large 
abscess  cavity  opening  into  the  bowels,  and  if  solid 
food  is  given  before  it  has  time  to  close,  it  is 
liable  to  find  its  way  into  this  cavity,  thereby  pre- 
venting healing,  and  bringing  on  a  chronic  condi- 
tion that  will  ultimately  end  in  death.  The  less 
food  taken  for  one  week  after  the  discharge  takes 
place,  the  better.  Any  rational  individual  should 
see  that  withholding  food  is  the  proper  treatment. 
Milk  should  be  thoroughly  mixed  with  saliva  or 
not  taken  at  all.  Remember  that  if  milk  is  not 
taken  with  great  deliberation,  and  great  care  given 
to  thoroughly  insalivate  each  sip,  then  it  amounts 
to  the  same  thing  as  eating  solid  food. 

Milk  is  a  solid  food  when  taken  into  the 
stomach  as  a  beverage  or  a  drink  like  water. 

In  appendicitis  all  nature  cries  out  for  rest, 
and  if  it  is  given  99  out  of  every  100  cases  will 
get  well  and  there  will  be  no  suffering  and  no 
danger  after  the  first  seventy-two  hours. 

The  ordinary  physician  sends  for  a  surgeon, 
and  if  he  is  a  victim  of  the  surgical  mania  the 
patient  must  be  operated  upon  at  once,  for  if 
twelve  or  twenty-four  hours  are  given,  the  condi- 
tions may  clear  up  and  an  operation  will  be  un- 


120  APPENDICITIS. 

necessary.  The  majority  of  surgeons  feel  that  they 
will  forfeit  their  right  to  heaven  if  they  do  not  cut 
at  once.  The  consequence  is  that  there  are  many 
patients  operated  upon  who  are  as  innocent  of 
having  the  disease  as  the  surgeon  is  innocent  of  a 
knowledge  of  a  better  plan  of  treatment. 

Of  course,  the  surgeon  declares  that  pus 
should  be  let  out  by  cutting  into  it,  or  it  is  liable 
to  break  into  the  peritoneal  cavity  and  cause  death. 
This  is  positively  not  the  truth,  for  when  an 
abscess  threatens  nature  at  once  proceeds  to  throw 
a  wall  around  in  order  to  avoid  accidents.  All 
around  the  point  of  prospective  abscesses,  heavy 
walls  of  adhesions  are  built,  and  if  nature  is  not 
interfered  with,  the  abscess  will  break  into  the 
gut,  because  it  is  the  point  of  least  resistance,  and 
it  is  also  the  point  favored  by  gravity.  The  sur- 
geons when  they  operate  in  these  cases  work  ex- 
actly opposite  to  nature. 

If  these  abscesses  are  allowed  to  open  into 
the  bowel  and  solid  food  is  kept  away  from  the 
patient,  full  and  uncomplicated  recovery  will  take 
place.  If  solid  food  is  given  too  soon  it  is  liable 
to  find  its  way  into  the  abscess  cavity  and  cause 
a  blind  fistula,  which  may  take  on  acute  inflam- 
mation at  any  time.  These  cases  then  become 
chronic  and  are  called  recurring  appendicitis.  It 
is  sound  surgery,  in  dealing  with  abscesses,  to 
find,  if  possible,  the  direction  nature  is  taking  to 
evacuate  pus  and  be  guided  by  this  suggestion  in 
evacuating  a  pus  cavity. 


OPERATION   DOOMED.  121 

In  order  to  cure  appendicitis  you  must  remove 
the  cause.  Cutting  off  the  appendix,  opening  an 
abscess,  withholding  food  till  the  acute  symptoms 
have  passed;  such  treatment  is  not  removing  the 
cause.  Nothing  short  of  changing  the  eating 
habits  of  the  patient  will  cure,  so  the  surgeon  who 
knows  nothing  about  food  and  its  action — what 
part  improper  eating  has  to  do  with  bringing  on 
the  disease — will  never  be  able  to  cure. 

Operating  for  this  disease  will  fall  into  disre- 
pute in  time,  for  there  are  already  cases  recurring 
and  the  second  and  third  operation  will  be  neces- 
sary among  those  who  survived  the  first.  There 
is  not  a  scintilla  of  logical  reasoning  in  defense  of 
the  operation.  Because  some  get  well  after  an 
operation  is  no  proof  that  the  operation  was  nec- 
essary; fortunately  for  the  operator  there  is  no 
way  to  prove  that,  the  case  operated  upon  would 
have  recovered  without  the  operation.  If  the  case 
be  not  complicated  by  bungling  treatment  an  oper- 
ation is  uncalled  for.  If  a  case  has  been  medicated 
and  fed  to  death — abused  to  the  extent  of  causing 
a  rupture  into  the  peritoneal  cavity — surgery 
must  be  resorted  to  as  the  only  hope. 

If  a  case  survive  an  operation  the  patient  is 
no  wiser  than  he  was  before,  and  knows  nothing 
about  avoiding  another  attack,  for  let  it  be  said 
loud  enough  to  be  heard  by  all,  and  with  no  fear  of 
successful  contradiction,  that  if  every  child  at 
birth  should   have  the  appendix  removed   there 


122  APPENDICITIS. 

would  not  be  one  case  less  of  appendicitis  than 
there  is  with  the  appendix  intact.  Of  course, 
technically  there  could  be  no  appendicitis  without 
an  appendix,  but  the  cecum  would  become  inflamed 
just  as  readily. 

No  amount  of  forcing  drugs  given  by  the 
mouth  can  induce  a  movement  from  above  the  con- 
striction, but  a  great  amount  of  pain  can  be  pro- 
duced by  attempting  to  force  a  passage.  No  one 
comprehending  the  true  state  of  affairs  would  be 
foolhardy  enough  to  try  to  force  the  bowels  to 
move.  The  reader  can  readily  imagine  the  great 
pain  and  danger  liable  to  follow  cathartic  drugs, 
for  they  stimulate  severe  peristaltic  contractions. 
The  contractions  drive  the  contents  of  the  small 
intestine  against  the  inflamed  cut-off,  but  there  it 
must  stop.  If  the  parts  have  become  softened, 
which  they  do  by  the  inflammation,  there  is  danger 
of  perforation  and  an  escape  of  the  contents  of  the 
bowels  into  the  peritoneal  cavity,  after  which  dif- 
fuse peritonitis  and  death  follow.  Surgery  can 
hardly  hope  to  save  such  patients;  in  fact  they 
usually  die;  this  is  why  the  surgeon  recommends 
an  early  operation. 

If  all  cases  are  to  be  so  abused  and  if  there 
were  no  better  way  to  treat  them  I  also  should  say, 
operate  at  once  as  soon  as  the  disease  is  discov- 
ered; but  I  know  from  years  of  experience  that 
there  is  a  better  way  to  care  for  these  patients. 


SUMMARY.  123 


CHAPTER  X. 

Allow  me  to  repeat:  As  soon  as  a  case  is 
diagnosed  the  proper  treatment  is  to  stop  all 
medicine  and  food,  for  they  excite  movement,  and 
this  should  be  avoided.  Give  nothing  but  water. 
Keep  ice  over  the  inflamed  spot.  Keep  the  pa- 
tient quiet,  and  the  feet  warm.  There  is  absolute- 
ly nothing  to  be  done  until  the  bowels  move,  which 
will  take  place  in  from  fourteen  to  twenty-eight 
days.  The  patient  will  not  starve  to  death,  nor 
will  there  be  any  danger  that  the  abscess  will  open 
anywhere  except  into  the  bowels.  After  the  bow- 
els move,  one  glass  of  hot  milk  is  to  be  given  three 
times  a  day,  so  there  will  be  no  danger  of  solid 
food  finding  its  way  into  the  cavity  of  the  abscess. 

To  be  safe  I  insist  on  a  fluid  diet  for  a  week 
after  the  bowels  move,  and  a  light  diet  for  two  or 
three  weeks  more.  Cases  taken  through  in  this 
way,  and  then  instructed  in  never  allowing  the 
bowels  to  become  loaded  again,  will  not  only  make 
a  good  recovery,  but  there  is  no  tendency  for  the 
disease  to  return  if  the  patient  is  prudent.  I  say 
that  there  need  not  be  a  death  from  this  disease 
if  these  suggestions  are  properly  carried  out.  The 
cases  that  die  every  year  are  killed  by  food  and 
medicine. 

Surgery  has  gained  its   reputation  in  these 


124  APPENDICITIS. 

cases  because  of  the  stupidity  of  the  average 
physician  and  patient.  Cases  taken  through  in 
this  way  are  comparatively  comfortable ;  they  may 
pretend  to  suffer  from  hunger,  but  it  is  principally 
imagination.  If  my  plan  were  generally  adopted 
the  dread  of  this  disease  would  disappear;  sur- 
geons would  get  left  on  some  fat  fees,  and  the  un- 
dertaker would  look  glum  after  the  fall  crop. 

There  are  a  few  laymen  so  wilful  and  incor- 
rigible that  they  can 't  be  depended  upon  to  follow 
instructions.  They  v/ill  break  rules,  be  imprudent 
in  eating,  and  in  many  ways  disregard  their  own 
interests.  Such  cases  should  be  sent  to  the  sur- 
geons as  early  as  possible,  before  they  have  time 
to  complicate  their  disease  and  make  a  complete 
recovery  impossible;  however,  people  with  such 
temperaments  usually  find  an  early  grave  and  they 
might  as  well  go  by  the  surgical  route  as  any 
other. 


INDEX  APPENDICITIS 


Page 

Abused  patient  still  has  chance 70 

Abscess  breaks  but  recovery  prevented 73 

Abscess  broke  in  19  days 110 

Abscess  cavity  walled  in 97 

Adhesions  remained  firm 80 

Allied  diseases 4 

American  surgeons 4 

Anatomical  position  of  cecum 15 

Another  parallel  case 107 

Appendicectomy  7 

Appendicitis  proper 30 

Artificial   collapse 71 

Autopsy  77 

Avoid  the  knife 39 

Bacteria  not  to  blame 18 

Bad  habits 84 

Best  etiology  and  treatment 7 

Bimanual  examinations 65 

Break  fast  on  liquid  foods 119 

Cardinal  symptoms .:.  47 

Cases   vary 41 

Chronic  appendicitis 30 

Chronic  bowel  trouble 25 

Comparison  of  two  cases 112 

Complete  obstruction  fatal 32 

Constipation  established 13 

Contrasting  methods  of  treatment 54 


INDEX 

Page 

Danger  of  rupturing  abscess  by  examinations 105 

Danger  in  disobeying  orders 110 

Dearly  bought  relief 58 

Death  relieves  patient 77 

Decline  rough  handling 117 

Disease  germs  versus  health  germs 28 

Doctors  innocent  of  thought 95 

Drug  and  pathological  symptoms  indistinguishable....  3,6 

Ectopic    pregnancy 34 

Effect  of  continuous  fast 109 

Embargo  causes  pain .-.  98 

End  of  sickness 110 

Etiology  11 

Evil  effects  of  opium 99 

False  professional  reasoning 22 

Fast  with  stomach  and  bowel  washes 118 

Fatal  interference  with  heart  and  lung  action 82 

Fatal  symptoms  partly  due  to  opium 107 

Fear  of  starvation 118 

Fecal  abscess 29 

Food  and  drugs  cause  discomfort 63 

Food  prolongs  disease 23 

Frightful  death  rate  follows  operations 38 

Fundamental  laws  of  health 12 

General  derangement  and  exciting  cause 97 

Graft 9 

Habitual  overeating 13 

Harmful  examinations 61 

Health  restored Ill 

History 4 

Hot  bath  and  no  food 112 

Hot  weather 84 

"Hurry  up"  operation 119 


APPENDICITIS 

Page 

Immunity  too  dearly  bought 24 

In  complete  obstruction  pain  continues 116 

Increasing  cecal  irritation 16 

Incorrect  diagnosis 60 

Inflammation  closes  the  appendix 17 

Inflammation  not  toxic 96 

Intoxicated  with  opium 92 

Irresponsible   practitioners 67 

Last  word  in  medicine  not  yet  said 75 

Learn  from   Nature 71 

Long  standing  inflammation 97 

Low  resistance 84 

Malpractice  23 

Malpractice  causes  infection 96 

Mania  to  operate 5 

Meaning  of  prolonged  nausea... 32 

Most  treatment  injurious 84 

Murderous  treatment 68 

My  belief 53 

Narcotism  mistaken  for  peritonitis 69 

Natural  fixation  of  parts 43 

Nature  cures  if  rest  is  allowed 80 

Nature  fights  against  heavy  odds 81 

Nature  says  "Rest" 42 

Nature's  cure 76 

Nature's  work  overcome  by  wily  physician 78 

Non-operative  plan  offers  better  chance 39 

Obstruction  not  complete 114 

Occasional  diarrhea 25 

Occasional  recovery  in  spite  of  all 37 

Ochsner  on  operation 37 

Only  local  peritonitis  was  possible 99 

Opium  and  gas  distention  fooled  doctors 103 


INDEX 

Page 

Opium  tympanitis 58 

Original  diarrhea  obviated  vomiting 104 

Ovariotomy  the  wedge 6 

Parallel  case 102 

Paroxysmal  pain 30 

Pathology 41 

Patient  rebels  and  eats  grapes 108 

Perforation  fatal  without  operation 33 

Phantom  peritonitis 75 

Plausible    theory 87 

Pre  and  proscriptions 107 

Prevailing  opinions . 34 

Process  of  reasoning  in  diagnosis 106 

Process  of  infection 85 

Proper  treatment 123 

Recurring  operations 121 

Relapses  all  caused  by  food  or  drugs 24 

Rest  alone  can  help 71 

Results  of  rupturing  pus  sac 44 

Rupturing  pus  sac  makes  surgery  necessary 66 

Scientific  explanation 79 

Self-treatment  in  appendicitis 117 

Senseless  abuse  of  patient 73 

Severe  colicky  pain  locating  in  cecum 45 

Similar  case 113 

Strategic  point  and  critical  time 27 

Structural  and  functional  derangement 20 

Structure  and  function  of  bowels 21 

Summary  123 

Symptoms 30,  32,  38,  45,  47 

Symptoms  and  diagnosis  do  not  agree 99 

Symptoms  of  diffuse  peritonitis 121 


APPENDICITIS 

Page 

Tenderness,  rigidity,  nausea  and  vomiting 46 

Toxic  poison 84 

Treatment  54,  76 

Trouble  may  locate  in  cecum  or  appendix 85 

Two  patients  in  same  condition 115 

Types  of  disease 29 

Unconscious  violation  of  laws  of  health 12 

Unwarranted  assumption  of  skill 63 

Value  of  symptoms 47 

Vomiting  kept  up  by  drugs 89 

Wall  of  defense 43 

Wearing  out  of  patient 61 

What  fools  we  mortals  be 87 


2002261 553 


